Provider Demographics
NPI:1306522909
Name:COOK, JEREMIAH EUGENE
Entity type:Individual
Prefix:
First Name:JEREMIAH
Middle Name:EUGENE
Last Name:COOK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2582 OLD ROSWELL RD SE UNIT B
Mailing Address - Street 2:
Mailing Address - City:SMYRNA
Mailing Address - State:GA
Mailing Address - Zip Code:30080-2112
Mailing Address - Country:US
Mailing Address - Phone:770-712-9062
Mailing Address - Fax:
Practice Address - Street 1:3516 BUSINESS 27
Practice Address - Street 2:
Practice Address - City:BUCHANAN
Practice Address - State:GA
Practice Address - Zip Code:30113-4813
Practice Address - Country:US
Practice Address - Phone:770-646-8294
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-27
Last Update Date:2023-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN1231091223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice