Provider Demographics
NPI:1396741203
Name:COOK, ELIZABETH ALICE (DMD)
Entity type:Individual
Prefix:DR
First Name:ELIZABETH
Middle Name:ALICE
Last Name:COOK
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:DR
Other - First Name:ELIZABETH
Other - Middle Name:ALICE
Other - Last Name:PECKHAM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DMD
Mailing Address - Street 1:7741 BALLANTYNE COMMONS PKWY
Mailing Address - Street 2:SUITE 101
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28277-2442
Mailing Address - Country:US
Mailing Address - Phone:704-845-0955
Mailing Address - Fax:704-845-0965
Practice Address - Street 1:7741 BALLANTYNE COMMONS PKWY
Practice Address - Street 2:SUITE 101
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28277-2442
Practice Address - Country:US
Practice Address - Phone:704-845-0955
Practice Address - Fax:704-845-0965
Is Sole Proprietor?:No
Enumeration Date:2005-06-24
Last Update Date:2008-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC78761223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5906299Medicaid