Provider Demographics
NPI:1912283136
Name:COOPER, MARISSA NICOLE (DMD)
Entity Type:Individual
Prefix:DR
First Name:MARISSA
Middle Name:NICOLE
Last Name:COOPER
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:700 SW 78TH AVE
Mailing Address - Street 2:APT. 917
Mailing Address - City:PLANTATION
Mailing Address - State:FL
Mailing Address - Zip Code:33324-3298
Mailing Address - Country:US
Mailing Address - Phone:772-215-3555
Mailing Address - Fax:
Practice Address - Street 1:140 S UNIVERSITY DR
Practice Address - Street 2:
Practice Address - City:PEMBROKE PINES
Practice Address - State:FL
Practice Address - Zip Code:33025-2234
Practice Address - Country:US
Practice Address - Phone:954-431-0004
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-02
Last Update Date:2011-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN186391223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics