Provider Demographics
NPI:1578864781
Name:COOPER, GARY WARD (DDS)
Entity Type:Individual
Prefix:DR
First Name:GARY
Middle Name:WARD
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 1:2110 SOUTHGATE RD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80906-2685
Mailing Address - Country:US
Mailing Address - Phone:719-635-5705
Mailing Address - Fax:
Practice Address - Street 1:2110 SOUTHGATE RD
Practice Address - Street 2:SUITE 200
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80906-2685
Practice Address - Country:US
Practice Address - Phone:719-635-5705
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-11-04
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD9562122300000X
CAD26831122300000X
AK1358122300000X
WADE60144920122300000X
KY9405122300000X
CODEN 202161122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA2186OtherACS
CO10250474OtherCO STATE BOARD OF PHARMACY, PDMP
AC7722259OtherDEA