Provider Demographics
NPI:1073775045
Name:COOPER, MICHAEL W (DDS)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:W
Last Name:COOPER
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:110 S INGLEWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:RUSSELLVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72801-3353
Mailing Address - Country:US
Mailing Address - Phone:479-968-4477
Mailing Address - Fax:
Practice Address - Street 1:110 S INGLEWOOD AVE
Practice Address - Street 2:
Practice Address - City:RUSSELLVILLE
Practice Address - State:AR
Practice Address - Zip Code:72801-3353
Practice Address - Country:US
Practice Address - Phone:479-968-4477
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-30
Last Update Date:2008-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR25691223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice