Provider Demographics
NPI:1851333710
Name:COOPER, JERIL RANSOM III (DMD)
Entity Type:Individual
Prefix:DR
First Name:JERIL
Middle Name:RANSOM
Last Name:COOPER
Suffix:III
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10621 HIGHWAY 11
Mailing Address - Street 2:
Mailing Address - City:TRENTON
Mailing Address - State:GA
Mailing Address - Zip Code:30752-3026
Mailing Address - Country:US
Mailing Address - Phone:706-657-7561
Mailing Address - Fax:706-675-8124
Practice Address - Street 1:10621 HIGHWAY 11
Practice Address - Street 2:
Practice Address - City:TRENTON
Practice Address - State:GA
Practice Address - Zip Code:30752-3026
Practice Address - Country:US
Practice Address - Phone:706-657-7561
Practice Address - Fax:706-675-8124
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-12
Last Update Date:2007-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA87551223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCZG8755Medicaid
GA00139598BMedicaid
GA00139598DMedicaid