Provider Demographics
NPI:1770606014
Name:COOPER ORAL & MAXILLOFACIAL SURGERY, PC
Entity type:Organization
Organization Name:COOPER ORAL & MAXILLOFACIAL SURGERY, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:LINDSEY
Authorized Official - Middle Name:W
Authorized Official - Last Name:COOPER
Authorized Official - Suffix:SR
Authorized Official - Credentials:DMD
Authorized Official - Phone:615-320-1392
Mailing Address - Street 1:207 TWENTY THIRD AVENUE NORTH
Mailing Address - Street 2:
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37203-1501
Mailing Address - Country:US
Mailing Address - Phone:615-320-1392
Mailing Address - Fax:615-329-4245
Practice Address - Street 1:207 TWENTY THIRD AVENUE NORTH
Practice Address - Street 2:
Practice Address - City:NASHVILLE
Practice Address - State:TN
Practice Address - Zip Code:37203-1501
Practice Address - Country:US
Practice Address - Phone:615-320-1392
Practice Address - Fax:615-329-4245
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-10
Last Update Date:2010-10-13
Deactivation Date:2010-10-04
Deactivation Code:
Reactivation Date:2010-10-12
Provider Licenses
StateLicense IDTaxonomies
TNDS30321223S0112X
TNDS72191223S0112X
TNDS46071223S0112X
TN30321223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3141185OtherBCBST SPENCER A HALEY
TN2006315OtherBCBST TIMOTHY D PROVENCE
TN2009819OtherBCBST LINDSEY W COOPER
TN3226410Medicare ID - Type UnspecifiedCOOPER & PROVENCE, PC
TN3223870Medicare ID - Type UnspecifiedLINDSEY W COOPER
TN2009819OtherBCBST LINDSEY W COOPER
TN3141185OtherBCBST SPENCER A HALEY
TN2006315OtherBCBST TIMOTHY D PROVENCE
TN3226483Medicare ID - Type UnspecifiedTIMOTHY D PROVENCE
TN3226504Medicare ID - Type UnspecifiedSPENCER A HALEY