Provider Demographics
NPI:1417976317
Name:COOK, CLIFFORD A (DDS)
Entity Type:Individual
Prefix:DR
First Name:CLIFFORD
Middle Name:A
Last Name:COOK
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6641 N HIGH ST
Mailing Address - Street 2:SUITE 105
Mailing Address - City:WORTHINGTON
Mailing Address - State:OH
Mailing Address - Zip Code:43085-4038
Mailing Address - Country:US
Mailing Address - Phone:614-885-3339
Mailing Address - Fax:
Practice Address - Street 1:6641 N HIGH ST
Practice Address - Street 2:SUITE 105
Practice Address - City:WORTHINGTON
Practice Address - State:OH
Practice Address - Zip Code:43085-4038
Practice Address - Country:US
Practice Address - Phone:614-885-3339
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-19
Last Update Date:2010-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH0177771223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0695142OtherMEDICARE ID
OHU18520Medicare UPIN