Provider Demographics
NPI:1952439580
Name:COOK, MICHELLE ANN (DDS)
Entity Type:Individual
Prefix:DR
First Name:MICHELLE
Middle Name:ANN
Last Name:COOK
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:619 ELM AVE STE 5
Mailing Address - Street 2:
Mailing Address - City:STORY CITY
Mailing Address - State:IA
Mailing Address - Zip Code:50248-1353
Mailing Address - Country:US
Mailing Address - Phone:515-733-5031
Mailing Address - Fax:515-733-6104
Practice Address - Street 1:619 ELM AVE STE 5
Practice Address - Street 2:
Practice Address - City:STORY CITY
Practice Address - State:IA
Practice Address - Zip Code:50248-1353
Practice Address - Country:US
Practice Address - Phone:515-733-5031
Practice Address - Fax:515-733-6104
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA081051223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA1238433Medicaid