Provider Demographics
NPI:1134259765
Name:COURTNEY, REBECCA COOLEY (DMD)
Entity type:Individual
Prefix:DR
First Name:REBECCA
Middle Name:COOLEY
Last Name:COURTNEY
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:134 CRITZ ST N
Mailing Address - Street 2:
Mailing Address - City:WIGGINS
Mailing Address - State:MS
Mailing Address - Zip Code:39577-3216
Mailing Address - Country:US
Mailing Address - Phone:601-928-7901
Mailing Address - Fax:601-928-2373
Practice Address - Street 1:134 CRITZ ST N
Practice Address - Street 2:
Practice Address - City:WIGGINS
Practice Address - State:MS
Practice Address - Zip Code:39577-3216
Practice Address - Country:US
Practice Address - Phone:601-928-7901
Practice Address - Fax:601-928-2373
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-06
Last Update Date:2017-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS3290-04122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS09302042Medicaid