Provider Demographics
NPI:1629203153
Name:COOK, CLIFFORD JAMES (DMD)
Entity Type:Individual
Prefix:DR
First Name:CLIFFORD
Middle Name:JAMES
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 1:4100 MCINNIS AVE
Mailing Address - Street 2:
Mailing Address - City:MOSS POINT
Mailing Address - State:MS
Mailing Address - Zip Code:39563
Mailing Address - Country:US
Mailing Address - Phone:228-475-0005
Mailing Address - Fax:
Practice Address - Street 1:4100 MCINNIS AVE
Practice Address - Street 2:
Practice Address - City:MOSS POINT
Practice Address - State:MS
Practice Address - Zip Code:39563-0000
Practice Address - Country:US
Practice Address - Phone:228-475-0005
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-05-28
Last Update Date:2011-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS3497-091223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice