Provider Demographics
NPI:1306935788
Name:COOK, JERRY WAYNE I (DDS)
Entity type:Individual
Prefix:
First Name:JERRY
Middle Name:WAYNE
Last Name:COOK
Suffix:I
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:303 BANCARIO STE 7
Mailing Address - Street 2:
Mailing Address - City:MARION
Mailing Address - State:AR
Mailing Address - Zip Code:72364-2826
Mailing Address - Country:US
Mailing Address - Phone:870-739-8799
Mailing Address - Fax:870-739-8799
Practice Address - Street 1:715 CALVIN AVERY DRIVE
Practice Address - Street 2:
Practice Address - City:WEST MEMPHIS
Practice Address - State:AR
Practice Address - Zip Code:72301
Practice Address - Country:US
Practice Address - Phone:870-735-3601
Practice Address - Fax:870-732-9535
Is Sole Proprietor?:No
Enumeration Date:2006-10-12
Last Update Date:2022-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR3113122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist