Provider Demographics
NPI:1477930352
Name:COOPER, JANELLE (DDS)
Entity Type:Individual
Prefix:
First Name:JANELLE
Middle Name:
Last Name:COOPER
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:811 W WELLINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60657-5123
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6900 E 10 MILE RD
Practice Address - Street 2:
Practice Address - City:CENTER LINE
Practice Address - State:MI
Practice Address - Zip Code:48015-1168
Practice Address - Country:US
Practice Address - Phone:586-467-0980
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-04-30
Last Update Date:2018-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MI2901021623122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program