Provider Demographics
NPI:1396897138
Name:COOMER, JASON RYAN (DMD)
Entity type:Individual
Prefix:DR
First Name:JASON
Middle Name:RYAN
Last Name:COOMER
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:203 S DIXIE HWY
Mailing Address - Street 2:
Mailing Address - City:CAVE CITY
Mailing Address - State:KY
Mailing Address - Zip Code:42127-8866
Mailing Address - Country:US
Mailing Address - Phone:270-773-3943
Mailing Address - Fax:270-773-3944
Practice Address - Street 1:203 S DIXIE HWY
Practice Address - Street 2:
Practice Address - City:CAVE CITY
Practice Address - State:KY
Practice Address - Zip Code:42127-8866
Practice Address - Country:US
Practice Address - Phone:270-773-3943
Practice Address - Fax:270-773-3944
Is Sole Proprietor?:No
Enumeration Date:2007-01-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY78691223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY60001435Medicaid