Provider Demographics
NPI:1104901628
Name:COOK, GLENN STATON (DMD)
Entity type:Individual
Prefix:DR
First Name:GLENN
Middle Name:STATON
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 1:1000 A NORTH HALSTEAD
Mailing Address - Street 2:
Mailing Address - City:OCEAN SPRINGS
Mailing Address - State:MS
Mailing Address - Zip Code:39564
Mailing Address - Country:US
Mailing Address - Phone:228-875-4428
Mailing Address - Fax:
Practice Address - Street 1:1000 N HALSTEAD RD
Practice Address - Street 2:A
Practice Address - City:OCEAN SPRINGS
Practice Address - State:MS
Practice Address - Zip Code:39564-3119
Practice Address - Country:US
Practice Address - Phone:228-875-4428
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS2473-89122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist