Provider Demographics
NPI:1083156145
Name:COOK, DENNIS JR
Entity Type:Individual
Prefix:
First Name:DENNIS
Middle Name:
Last Name:COOK
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12735 QUICKSILVER ST
Mailing Address - Street 2:
Mailing Address - City:WATERFORD
Mailing Address - State:CA
Mailing Address - Zip Code:95386-9326
Mailing Address - Country:US
Mailing Address - Phone:209-596-7797
Mailing Address - Fax:
Practice Address - Street 1:12735 QUICKSILVER ST
Practice Address - Street 2:
Practice Address - City:WATERFORD
Practice Address - State:CA
Practice Address - Zip Code:95386-9326
Practice Address - Country:US
Practice Address - Phone:209-596-7797
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-11-07
Last Update Date:2016-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAVN292529164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse