Provider Demographics
NPI:1750587085
Name:COOKE, GARY STEWART (DMD)
Entity type:Individual
Prefix:
First Name:GARY
Middle Name:STEWART
Last Name:COOKE
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 1:490 E POWELL BLVD
Mailing Address - Street 2:
Mailing Address - City:GRESHAM
Mailing Address - State:OR
Mailing Address - Zip Code:97030-7610
Mailing Address - Country:US
Mailing Address - Phone:503-665-6166
Mailing Address - Fax:503-661-7236
Practice Address - Street 1:490 E POWELL BLVD
Practice Address - Street 2:
Practice Address - City:GRESHAM
Practice Address - State:OR
Practice Address - Zip Code:97030-7610
Practice Address - Country:US
Practice Address - Phone:503-665-6166
Practice Address - Fax:503-661-7236
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR47121223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice