Provider Demographics
NPI:1417123456
Name:COOK, DANIEL R (DDS, MD)
Entity Type:Individual
Prefix:
First Name:DANIEL
Middle Name:R
Last Name:COOK
Suffix:
Gender:M
Credentials:DDS, MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:130 LAKE CONCORD RD.
Mailing Address - Street 2:
Mailing Address - City:CONCORD
Mailing Address - State:NC
Mailing Address - Zip Code:28025
Mailing Address - Country:US
Mailing Address - Phone:704-788-1192
Mailing Address - Fax:704-788-1178
Practice Address - Street 1:130 LAKE CONCORD RD
Practice Address - Street 2:
Practice Address - City:CONCORD
Practice Address - State:NC
Practice Address - Zip Code:28025
Practice Address - Country:US
Practice Address - Phone:504-913-4788
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-04-30
Last Update Date:2016-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAS-4071223S0112X
NC80691223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery