Provider Demographics
NPI:1922173913
Name:TODD T COOLEY DDS
Entity Type:Organization
Organization Name:TODD T COOLEY DDS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:TODD
Authorized Official - Middle Name:THOMAS
Authorized Official - Last Name:COOLEY
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:360-424-8884
Mailing Address - Street 1:2124 RIVERSIDE DR
Mailing Address - Street 2:SUITE 108
Mailing Address - City:MOUNT VERNON
Mailing Address - State:WA
Mailing Address - Zip Code:98273
Mailing Address - Country:US
Mailing Address - Phone:360-424-8884
Mailing Address - Fax:360-424-1640
Practice Address - Street 1:2124 RIVERSIDE DR
Practice Address - Street 2:SUITE 108
Practice Address - City:MOUNT VERNON
Practice Address - State:WA
Practice Address - Zip Code:98273
Practice Address - Country:US
Practice Address - Phone:360-424-8884
Practice Address - Fax:360-424-1640
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-22
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE000100791223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA5048459Medicaid