Provider Demographics
NPI:1396866026
Name:KEVIN B. COOK, D.D.S., S.C.
Entity Type:Organization
Organization Name:KEVIN B. COOK, D.D.S., S.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT AND TREASURER
Authorized Official - Prefix:DR
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:BURTON
Authorized Official - Last Name:COOK
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:608-782-9667
Mailing Address - Street 1:1800 STATE ROAD 16
Mailing Address - Street 2:
Mailing Address - City:LA CROSSE
Mailing Address - State:WI
Mailing Address - Zip Code:54601-3011
Mailing Address - Country:US
Mailing Address - Phone:608-782-9667
Mailing Address - Fax:
Practice Address - Street 1:1800 STATE ROAD 16
Practice Address - Street 2:
Practice Address - City:LA CROSSE
Practice Address - State:WI
Practice Address - Zip Code:54601-3011
Practice Address - Country:US
Practice Address - Phone:608-782-9667
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-02
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI32791223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI33716100Medicaid