Provider Demographics
NPI:1457716870
Name:WAYNE COOK DENTISRTY LLC
Entity Type:Organization
Organization Name:WAYNE COOK DENTISRTY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JERRY
Authorized Official - Middle Name:WAYNE
Authorized Official - Last Name:COOK
Authorized Official - Suffix:JR
Authorized Official - Credentials:DDS
Authorized Official - Phone:870-739-8799
Mailing Address - Street 1:303 BANCARIO STE 7
Mailing Address - Street 2:
Mailing Address - City:MARION
Mailing Address - State:AR
Mailing Address - Zip Code:72364-2826
Mailing Address - Country:US
Mailing Address - Phone:870-739-8799
Mailing Address - Fax:870-739-8675
Practice Address - Street 1:303 BANCARIO STE 7
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:AR
Practice Address - Zip Code:72364-2826
Practice Address - Country:US
Practice Address - Phone:870-739-8799
Practice Address - Fax:870-739-8675
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-12-30
Last Update Date:2015-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR3113261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR128223608Medicaid