Provider Demographics
NPI:1386191252
Name:COOPER, KELLY (DDS)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name: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 1:221 3RD ST W BLDG 1040
Mailing Address - Street 2:
Mailing Address - City:JBSA RANDOLPH
Mailing Address - State:TX
Mailing Address - Zip Code:78150-4800
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:221 3RD ST W BLDG 1040
Practice Address - Street 2:
Practice Address - City:JBSA RANDOLPH
Practice Address - State:TX
Practice Address - Zip Code:78150-4800
Practice Address - Country:US
Practice Address - Phone:210-652-3301
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-09-07
Last Update Date:2020-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX323651223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice