Provider Demographics
NPI:1952456998
Name:HENRY L COOK D D S P C
Entity Type:Organization
Organization Name:HENRY L COOK D D S P C
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:HENRY
Authorized Official - Middle Name:L
Authorized Official - Last Name:COOK
Authorized Official - Suffix:
Authorized Official - Credentials:DDS PC
Authorized Official - Phone:706-322-3218
Mailing Address - Street 1:1190 MARTIN LUTHER KING JR BLVD
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:GA
Mailing Address - Zip Code:31906-3527
Mailing Address - Country:US
Mailing Address - Phone:706-322-3218
Mailing Address - Fax:706-322-3219
Practice Address - Street 1:1190 MARTIN LUTHER KING JR BLVD
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:GA
Practice Address - Zip Code:31906-3665
Practice Address - Country:US
Practice Address - Phone:706-322-3218
Practice Address - Fax:706-322-3219
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-23
Last Update Date:2013-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA75401223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00056933A2Medicaid