Provider Demographics
NPI:1215545710
Name:COOPER, JUSTIN MICHAEL (DDS)
Entity Type:Individual
Prefix:DR
First Name:JUSTIN
Middle Name:MICHAEL
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 1:1400 MEADOW BRIDGE DR
Mailing Address - Street 2:
Mailing Address - City:GREENWOOD
Mailing Address - State:AR
Mailing Address - Zip Code:72936-3059
Mailing Address - Country:US
Mailing Address - Phone:479-996-6736
Mailing Address - Fax:
Practice Address - Street 1:5008 S U ST STE 101A
Practice Address - Street 2:
Practice Address - City:FORT SMITH
Practice Address - State:AR
Practice Address - Zip Code:72903-3613
Practice Address - Country:US
Practice Address - Phone:479-431-2527
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-21
Last Update Date:2020-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR44361223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice