Provider Demographics
NPI:1619086337
Name:COOK, EARNEST (DDS)
Entity Type:Individual
Prefix:MR
First Name:EARNEST
Middle Name:
Last Name:COOK
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 1:3989 SALEM AVENUE
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45406-1531
Mailing Address - Country:US
Mailing Address - Phone:937-277-8766
Mailing Address - Fax:937-277-6291
Practice Address - Street 1:3989 SALEM AVENUE
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45406-1531
Practice Address - Country:US
Practice Address - Phone:937-277-8766
Practice Address - Fax:937-277-6291
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-29
Last Update Date:2013-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH30 01 4803122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0340036Medicaid