Provider Demographics
NPI:1801899620
Name:COOK, MICHAEL STACY (DMD)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:STACY
Last Name:COOK
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:PO BOX 280
Mailing Address - Street 2:
Mailing Address - City:LEAKESVILLE
Mailing Address - State:MS
Mailing Address - Zip Code:39451-0280
Mailing Address - Country:US
Mailing Address - Phone:601-394-2467
Mailing Address - Fax:301-394-2468
Practice Address - Street 1:403 MAIN ST
Practice Address - Street 2:
Practice Address - City:LEAKESVILLE
Practice Address - State:MS
Practice Address - Zip Code:39451-6502
Practice Address - Country:US
Practice Address - Phone:601-394-2467
Practice Address - Fax:601-394-2468
Is Sole Proprietor?:Yes
Enumeration Date:2005-05-24
Last Update Date:2022-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS2870-95122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS09015334Medicaid