Provider Demographics
NPI:1932319563
Name:COOK, JUSTIN RYAN (DDS)
Entity Type:Individual
Prefix:DR
First Name:JUSTIN
Middle Name:RYAN
Last Name:COOK
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 1:1513 BURBANK DR.
Mailing Address - Street 2:
Mailing Address - City:SAINT JOHNS
Mailing Address - State:MI
Mailing Address - Zip Code:48879
Mailing Address - Country:US
Mailing Address - Phone:517-202-7765
Mailing Address - Fax:
Practice Address - Street 1:2277 SCIENCE PRKWY
Practice Address - Street 2:
Practice Address - City:OKEMOS
Practice Address - State:MI
Practice Address - Zip Code:48864-2551
Practice Address - Country:US
Practice Address - Phone:517-349-6669
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2901019571122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist