Provider Demographics
NPI:1679562029
Name:COOPER, KEVIN C (DDS)
Entity Type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:C
Last Name:COOPER
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 1:3105 WESTERN BRANCH BLVD
Mailing Address - Street 2:SUITE 5
Mailing Address - City:CHESAPEAKE
Mailing Address - State:VA
Mailing Address - Zip Code:23321-5540
Mailing Address - Country:US
Mailing Address - Phone:757-483-5152
Mailing Address - Fax:757-483-7711
Practice Address - Street 1:3105 WESTERN BRANCH BLVD
Practice Address - Street 2:SUITE 5
Practice Address - City:CHESAPEAKE
Practice Address - State:VA
Practice Address - Zip Code:23321-5540
Practice Address - Country:US
Practice Address - Phone:757-483-5152
Practice Address - Fax:757-483-7711
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-10-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0401005946122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist