Provider Demographics
NPI:1124464938
Name:STEVEN R. & JENNIFER S. COOPER DMD PA
Entity type:Organization
Organization Name:STEVEN R. & JENNIFER S. COOPER DMD PA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER DOCTOR
Authorized Official - Prefix:
Authorized Official - First Name:STEVEN
Authorized Official - Middle Name:R
Authorized Official - Last Name:COOPER
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:386-672-0955
Mailing Address - Street 1:1275 W. GRANADA BLVD., SUITE 1
Mailing Address - Street 2:
Mailing Address - City:ORMOND BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32174
Mailing Address - Country:US
Mailing Address - Phone:386-672-0955
Mailing Address - Fax:386-672-5177
Practice Address - Street 1:1275 W. GRANADA BLVD., SUITE 1
Practice Address - Street 2:
Practice Address - City:ORMOND BEACH
Practice Address - State:FL
Practice Address - Zip Code:32174
Practice Address - Country:US
Practice Address - Phone:386-672-0955
Practice Address - Fax:386-672-5177
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-05-20
Last Update Date:2013-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty