Provider Demographics
NPI:1417463308
Name:NATHAN C COONEY DDS PC
Entity Type:Organization
Organization Name:NATHAN C COONEY DDS PC
Other - Org Name:COONEY FAMILY DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:ELISE
Authorized Official - Middle Name:NICOLE
Authorized Official - Last Name:VAN TASSELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-779-6037
Mailing Address - Street 1:1792 W 1700 S STE 203
Mailing Address - Street 2:
Mailing Address - City:SYRACUSE
Mailing Address - State:UT
Mailing Address - Zip Code:84075-9651
Mailing Address - Country:US
Mailing Address - Phone:801-779-6037
Mailing Address - Fax:801-820-2774
Practice Address - Street 1:1792 W 1700 S STE 203
Practice Address - Street 2:
Practice Address - City:SYRACUSE
Practice Address - State:UT
Practice Address - Zip Code:84075-9651
Practice Address - Country:US
Practice Address - Phone:801-779-6037
Practice Address - Fax:801-820-2774
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-12-14
Last Update Date:2023-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT80289261223G0001X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT1619263894Medicaid