Provider Demographics
NPI:1245796002
Name:FIELDS-COOPER, MARIAH MARISSA (DDS)
Entity Type:Individual
Prefix:
First Name:MARIAH
Middle Name:MARISSA
Last Name:FIELDS-COOPER
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1499 E MARSHALL AVE
Mailing Address - Street 2:
Mailing Address - City:LONGVIEW
Mailing Address - State:TX
Mailing Address - Zip Code:75601-6814
Mailing Address - Country:US
Mailing Address - Phone:903-242-9777
Mailing Address - Fax:903-242-9778
Practice Address - Street 1:1499 E MARSHALL AVE
Practice Address - Street 2:
Practice Address - City:LONGVIEW
Practice Address - State:TX
Practice Address - Zip Code:75601-6814
Practice Address - Country:US
Practice Address - Phone:903-242-9777
Practice Address - Fax:903-242-9778
Is Sole Proprietor?:No
Enumeration Date:2019-02-18
Last Update Date:2019-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX348561223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice