Provider Demographics
NPI:1831593763
Name:KEVIN COOK ORTHODONTICS
Entity type:Organization
Organization Name:KEVIN COOK ORTHODONTICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR/ OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:KEVIN
Authorized Official - Last Name:COOK
Authorized Official - Suffix:
Authorized Official - Credentials:DDS, MS
Authorized Official - Phone:618-997-6640
Mailing Address - Street 1:3108 W. DEYOUNG ST.
Mailing Address - Street 2:SUITE A
Mailing Address - City:MARION
Mailing Address - State:IL
Mailing Address - Zip Code:62959-5548
Mailing Address - Country:US
Mailing Address - Phone:618-997-6640
Mailing Address - Fax:618-997-6641
Practice Address - Street 1:3108 W. DEYOUNG ST.
Practice Address - Street 2:SUITE A
Practice Address - City:MARION
Practice Address - State:IL
Practice Address - Zip Code:62959-5548
Practice Address - Country:US
Practice Address - Phone:618-997-6640
Practice Address - Fax:618-997-6641
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-10-21
Last Update Date:2016-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0210022091223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty