Provider Demographics
NPI:1912033440
Name:COOPER, GREG W (DDS)
Entity type:Individual
Prefix:DR
First Name:GREG
Middle Name:W
Last Name:COOPER
Suffix:
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 1:4332 CERRITOS AVE
Mailing Address - Street 2:SUITE 103
Mailing Address - City:LOS ALAMITOS
Mailing Address - State:CA
Mailing Address - Zip Code:90720-2557
Mailing Address - Country:US
Mailing Address - Phone:714-827-0206
Mailing Address - Fax:
Practice Address - Street 1:4332 CERRITOS AVE
Practice Address - Street 2:SUITE 103
Practice Address - City:LOS ALAMITOS
Practice Address - State:CA
Practice Address - Zip Code:90720-2557
Practice Address - Country:US
Practice Address - Phone:714-827-0206
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA254971223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice