Provider Demographics
NPI:1457376782
Name:COOPER, SEAN A (DDS)
Entity Type:Individual
Prefix:DR
First Name:SEAN
Middle Name:A
Last Name:COOPER
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1105 12TH ST SE
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97302-2810
Mailing Address - Country:US
Mailing Address - Phone:503-363-5865
Mailing Address - Fax:503-363-8510
Practice Address - Street 1:1105 12TH ST SE
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97302-2810
Practice Address - Country:US
Practice Address - Phone:503-363-5865
Practice Address - Fax:503-363-8510
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-13
Last Update Date:2012-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD73751223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR150611Medicaid
93-1284165OtherFEDERAL TAX ID NUMBER