Provider Demographics
NPI:1841283975
Name:COOPER, ERNEST W (DDS)
Entity type:Individual
Prefix:
First Name:ERNEST
Middle Name:W
Last Name:COOPER
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:515 E WATAUGA AVE
Mailing Address - Street 2:
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37601-4038
Mailing Address - Country:US
Mailing Address - Phone:423-928-2621
Mailing Address - Fax:423-928-2263
Practice Address - Street 1:515 E WATAUGA AVE
Practice Address - Street 2:
Practice Address - City:JOHNSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37601-4038
Practice Address - Country:US
Practice Address - Phone:423-928-2621
Practice Address - Fax:423-928-2263
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-08-24
Last Update Date:2007-07-08
Deactivation Date:2006-03-27
Deactivation Code:
Reactivation Date:2006-04-04
Provider Licenses
StateLicense IDTaxonomies
TNDS00000032751223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN0016346OtherTENNCARE