Provider Demographics
NPI:1467765321
Name:COOK, BRIAN KELLY
Entity Type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:KELLY
Last Name:COOK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1915 W PARK DR STE 104
Mailing Address - Street 2:
Mailing Address - City:NORTH WILKESBORO
Mailing Address - State:NC
Mailing Address - Zip Code:28659-3777
Mailing Address - Country:US
Mailing Address - Phone:336-903-7300
Mailing Address - Fax:336-903-0464
Practice Address - Street 1:1915 W PARK DR STE 104
Practice Address - Street 2:
Practice Address - City:NORTH WILKESBORO
Practice Address - State:NC
Practice Address - Zip Code:28659-3777
Practice Address - Country:US
Practice Address - Phone:336-903-7300
Practice Address - Fax:336-903-0464
Is Sole Proprietor?:No
Enumeration Date:2010-07-21
Last Update Date:2010-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC89841223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice