Provider Demographics
NPI:1710056635
Name:J SELIG COOPER DDS PA
Entity Type:Organization
Organization Name:J SELIG COOPER DDS PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JAVON
Authorized Official - Middle Name:SELIG
Authorized Official - Last Name:COOPER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:336-510-5813
Mailing Address - Street 1:1515 YANCEYVILLE ST
Mailing Address - Street 2:
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27405-6958
Mailing Address - Country:US
Mailing Address - Phone:336-510-5813
Mailing Address - Fax:336-510-5812
Practice Address - Street 1:1515 YANCEYVILLE ST
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27405-6958
Practice Address - Country:US
Practice Address - Phone:336-510-5813
Practice Address - Fax:336-510-5812
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-07
Last Update Date:2008-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC6552122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC9002FOtherBCBSNC PROVIDER #
NC799002FMedicaid