Provider Demographics
NPI:1659891984
Name:COOPER, GEORGE ROBERT IV (DMD)
Entity Type:Individual
Prefix:DR
First Name:GEORGE
Middle Name:ROBERT
Last Name:COOPER
Suffix:IV
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 1:2121 E DUPONT RD STE E
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46825-1546
Mailing Address - Country:US
Mailing Address - Phone:260-489-1508
Mailing Address - Fax:
Practice Address - Street 1:2121 E DUPONT RD
Practice Address - Street 2:SUITE E
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46825
Practice Address - Country:US
Practice Address - Phone:260-489-1508
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-27
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12012761A122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist