Provider Demographics
NPI:1922165075
Name:COOPER, PHILIP WENDELL JR (DDS)
Entity Type:Individual
Prefix:DR
First Name:PHILIP
Middle Name:WENDELL
Last Name:COOPER
Suffix:JR
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 1:413 W DUFFY ST
Mailing Address - Street 2:
Mailing Address - City:SAVANNAH
Mailing Address - State:GA
Mailing Address - Zip Code:31401-6716
Mailing Address - Country:US
Mailing Address - Phone:912-234-5003
Mailing Address - Fax:912-234-2844
Practice Address - Street 1:413 W DUFFY ST
Practice Address - Street 2:
Practice Address - City:SAVANNAH
Practice Address - State:GA
Practice Address - Zip Code:31401-6716
Practice Address - Country:US
Practice Address - Phone:912-234-5003
Practice Address - Fax:912-234-2844
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAGA84121223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAGA8412OtherLICENSE
GA00045251AMedicaid
GA9184118OtherDORAL-GA. MEDICAID
SCZAG994Medicaid