Provider Demographics
NPI:1265730287
Name:JERRY E COOPER DDS, SC
Entity type:Organization
Organization Name:JERRY E COOPER DDS, SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JERRY
Authorized Official - Middle Name:EDWARD
Authorized Official - Last Name:COOPER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:920-452-1110
Mailing Address - Street 1:1407 N 8TH ST
Mailing Address - Street 2:
Mailing Address - City:SHEBOYGAN
Mailing Address - State:WI
Mailing Address - Zip Code:53081-3400
Mailing Address - Country:US
Mailing Address - Phone:920-452-1110
Mailing Address - Fax:920-452-1996
Practice Address - Street 1:1407 N 8TH ST
Practice Address - Street 2:
Practice Address - City:SHEBOYGAN
Practice Address - State:WI
Practice Address - Zip Code:53081-3400
Practice Address - Country:US
Practice Address - Phone:920-452-1110
Practice Address - Fax:920-452-1996
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-03-01
Last Update Date:2011-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI6314-015261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental