Provider Demographics
NPI:1104222173
Name:COOPER, CHARLES JR
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:
Last Name:COOPER
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 1:3200 S KINGS HWY
Mailing Address - Street 2:
Mailing Address - City:CUSHING
Mailing Address - State:OK
Mailing Address - Zip Code:74023-5355
Mailing Address - Country:US
Mailing Address - Phone:918-225-3336
Mailing Address - Fax:918-223-2937
Practice Address - Street 1:3200 S KINGS HWY
Practice Address - Street 2:
Practice Address - City:CUSHING
Practice Address - State:OK
Practice Address - Zip Code:74023-5355
Practice Address - Country:US
Practice Address - Phone:918-225-3336
Practice Address - Fax:918-223-2937
Is Sole Proprietor?:No
Enumeration Date:2014-11-18
Last Update Date:2014-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK5163122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist