Provider Demographics
NPI:1558534917
Name:COOPER, ALAN RAY (DDS)
Entity Type:Individual
Prefix:
First Name:ALAN
Middle Name:RAY
Last Name:COOPER
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 1:640 S WOODRUFF AVE
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83401-5299
Mailing Address - Country:US
Mailing Address - Phone:208-523-5400
Mailing Address - Fax:208-528-0565
Practice Address - Street 1:640 S WOODRUFF AVE
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83401-5299
Practice Address - Country:US
Practice Address - Phone:208-523-5400
Practice Address - Fax:208-528-0565
Is Sole Proprietor?:No
Enumeration Date:2008-04-08
Last Update Date:2008-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD18901223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice