Provider Demographics
NPI:1477334381
Name:COOPER DENTAL GROUP
Entity Type:Organization
Organization Name:COOPER DENTAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EMPLOYER
Authorized Official - Prefix:
Authorized Official - First Name:STEVEN
Authorized Official - Middle Name:
Authorized Official - Last Name:COOPER
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:386-547-7000
Mailing Address - Street 1:1275 W GRANADA BLVD FL 32174
Mailing Address - Street 2:
Mailing Address - City:ORMOND BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32174-8259
Mailing Address - Country:US
Mailing Address - Phone:386-244-9838
Mailing Address - Fax:
Practice Address - Street 1:1275 W GRANADA BLVD FL 32174
Practice Address - Street 2:
Practice Address - City:ORMOND BEACH
Practice Address - State:FL
Practice Address - Zip Code:32174-8259
Practice Address - Country:US
Practice Address - Phone:386-244-9838
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-10-09
Last Update Date:2023-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty