Provider Demographics
NPI:1912994914
Name:COOPER, ANGELA M (DDS)
Entity Type:Individual
Prefix:
First Name:ANGELA
Middle Name:M
Last Name:COOPER
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:47 5TH ST NW
Mailing Address - Street 2:
Mailing Address - City:WINTER HAVEN
Mailing Address - State:FL
Mailing Address - Zip Code:33881-4672
Mailing Address - Country:US
Mailing Address - Phone:863-291-5110
Mailing Address - Fax:863-291-5128
Practice Address - Street 1:204 E PALMETTO ST
Practice Address - Street 2:
Practice Address - City:WAUCHULA
Practice Address - State:FL
Practice Address - Zip Code:33873-2732
Practice Address - Country:US
Practice Address - Phone:863-773-2111
Practice Address - Fax:863-773-3429
Is Sole Proprietor?:No
Enumeration Date:2005-10-04
Last Update Date:2016-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN132551223D0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223D0001XDental ProvidersDentistDental Public Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL075129400Medicaid