Provider Demographics
NPI:1578903217
Name:COOK, CLAYTON KOTTER (DMD)
Entity Type:Individual
Prefix:
First Name:CLAYTON
Middle Name:KOTTER
Last Name:COOK
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6708 S HULEN ST STE 3
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76133-5243
Mailing Address - Country:US
Mailing Address - Phone:817-294-1090
Mailing Address - Fax:
Practice Address - Street 1:6708 S HULEN ST STE 3
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76133-5243
Practice Address - Country:US
Practice Address - Phone:817-294-1090
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-26
Last Update Date:2021-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX29154122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist