Provider Demographics
NPI:1134509813
Name:COOK, MARY OLIVIA (DMD)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:OLIVIA
Last Name:COOK
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:OLIVIA
Other - Middle Name:BASS
Other - Last Name:COOK
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DMD
Mailing Address - Street 1:305 W 12TH AVE
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43210-1267
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1 WOODGREEN PL STE 100
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:MS
Practice Address - Zip Code:39110-8161
Practice Address - Country:US
Practice Address - Phone:601-605-5015
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-06-08
Last Update Date:2019-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH30.024519122300000X
MSENDO-537-171223E0200X
MS3889-16122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223E0200XDental ProvidersDentistEndodontics