Provider Demographics
NPI:1710958863
Name:COONEY, THOMAS RAY (DDS)
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:RAY
Last Name:COONEY
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 1:215 N BUXTON ST
Mailing Address - Street 2:
Mailing Address - City:INDIANOLA
Mailing Address - State:IA
Mailing Address - Zip Code:50125-2430
Mailing Address - Country:US
Mailing Address - Phone:515-961-5351
Mailing Address - Fax:515-961-5352
Practice Address - Street 1:215 N BUXTON ST
Practice Address - Street 2:
Practice Address - City:INDIANOLA
Practice Address - State:IA
Practice Address - Zip Code:50125-2430
Practice Address - Country:US
Practice Address - Phone:515-961-5351
Practice Address - Fax:515-961-5352
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-27
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA073101223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0050054Medicaid