Provider Demographics
NPI:1396866125
Name:COOPER, JENNIFER S (DMD)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:S
Last Name:COOPER
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1275 WEST GRANADA BLVD.
Mailing Address - Street 2:SUITE 1
Mailing Address - City:ORMOND BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32174
Mailing Address - Country:US
Mailing Address - Phone:386-672-0955
Mailing Address - Fax:386-672-5177
Practice Address - Street 1:1275 W GRANADA BLVD
Practice Address - Street 2:SUITE 1
Practice Address - City:ORMOND BEACH
Practice Address - State:FL
Practice Address - Zip Code:32174-8259
Practice Address - Country:US
Practice Address - Phone:386-672-0955
Practice Address - Fax:386-672-5177
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN 12068122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist