Provider Demographics
NPI:1518038728
Name:MICHAEL W. COOPER, D.D.S., P.A.
Entity Type:Organization
Organization Name:MICHAEL W. COOPER, D.D.S., P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:W
Authorized Official - Last Name:COOPER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:479-968-4477
Mailing Address - Street 1:110 S INGLEWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:RUSSELLVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72801-3353
Mailing Address - Country:US
Mailing Address - Phone:479-968-4477
Mailing Address - Fax:479-968-4498
Practice Address - Street 1:110 S INGLEWOOD AVE
Practice Address - Street 2:
Practice Address - City:RUSSELLVILLE
Practice Address - State:AR
Practice Address - Zip Code:72801-3353
Practice Address - Country:US
Practice Address - Phone:479-968-4477
Practice Address - Fax:479-968-4498
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-10
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR25691223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty