Provider Demographics
NPI:1588011845
Name:DIFFERDING, COOPER (DDS)
Entity type:Individual
Prefix:DR
First Name:COOPER
Middle Name:
Last Name:DIFFERDING
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 1:10 WILLOW ST STE 6
Mailing Address - Street 2:
Mailing Address - City:MILL VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:94941-2895
Mailing Address - Country:US
Mailing Address - Phone:415-388-6100
Mailing Address - Fax:
Practice Address - Street 1:10 WILLOW ST
Practice Address - Street 2:
Practice Address - City:MILL VALLEY
Practice Address - State:CA
Practice Address - Zip Code:94941-2845
Practice Address - Country:US
Practice Address - Phone:415-388-6100
Practice Address - Fax:415-388-6100
Is Sole Proprietor?:No
Enumeration Date:2016-05-17
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA64885122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist