Provider Demographics
NPI:1841601291
Name:COOK CHILDRENS PHYSICIAN NETWORK
Entity Type:Organization
Organization Name:COOK CHILDRENS PHYSICIAN NETWORK
Other - Org Name:COOK CHILDREN'S DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT, CCPN
Authorized Official - Prefix:
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:V
Authorized Official - Last Name:DZURIK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:682-885-1416
Mailing Address - Street 1:PO BOX 732669
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75373-2669
Mailing Address - Country:US
Mailing Address - Phone:817-347-4600
Mailing Address - Fax:817-347-4639
Practice Address - Street 1:2600 E BERRY STREET
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76105-4750
Practice Address - Country:US
Practice Address - Phone:817-347-4600
Practice Address - Fax:817-347-4639
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:COOK CHILDRENS PHYSICIAN NETWORK
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-05-19
Last Update Date:2021-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1404428A9OtherDE1