Provider Demographics
NPI:1821203613
Name:COOLEY, RAY L (DDS)
Entity Type:Individual
Prefix:DR
First Name:RAY
Middle Name:L
Last Name:COOLEY
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 1:134 CRITZ ST N
Mailing Address - Street 2:
Mailing Address - City:WIGGINS
Mailing Address - State:MS
Mailing Address - Zip Code:39577-3216
Mailing Address - Country:US
Mailing Address - Phone:601-928-7901
Mailing Address - Fax:601-928-2373
Practice Address - Street 1:134 CRITZ ST N
Practice Address - Street 2:
Practice Address - City:WIGGINS
Practice Address - State:MS
Practice Address - Zip Code:39577-3216
Practice Address - Country:US
Practice Address - Phone:601-928-7901
Practice Address - Fax:601-928-2373
Is Sole Proprietor?:No
Enumeration Date:2007-05-14
Last Update Date:2017-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS1357-69122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS0060560Medicaid
MS0060560Medicaid