Provider Demographics
NPI:1689097826
Name:COOPER, JOHN MITCHELL (DDS)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:MITCHELL
Last Name:COOPER
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:DR
Other - First Name:MITCH
Other - Middle Name:
Other - Last Name:COOPER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DDS
Mailing Address - Street 1:1813 SW FAIRLAWN RD
Mailing Address - Street 2:
Mailing Address - City:TOPEKA
Mailing Address - State:KS
Mailing Address - Zip Code:66604-3646
Mailing Address - Country:US
Mailing Address - Phone:785-272-9443
Mailing Address - Fax:785-228-9071
Practice Address - Street 1:1813 SW FAIRLAWN RD
Practice Address - Street 2:
Practice Address - City:TOPEKA
Practice Address - State:KS
Practice Address - Zip Code:66604-3646
Practice Address - Country:US
Practice Address - Phone:785-272-9443
Practice Address - Fax:785-228-9071
Is Sole Proprietor?:Yes
Enumeration Date:2014-01-23
Last Update Date:2015-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS5956122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS1376658815OtherORGANIZATION