Provider Demographics
NPI:1912647199
Name:COOPER, SIERRA DANAE (DMD)
Entity type:Individual
Prefix:
First Name:SIERRA
Middle Name:DANAE
Last Name:COOPER
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22 RACEWAY RD
Mailing Address - Street 2:
Mailing Address - City:JERICHO
Mailing Address - State:VT
Mailing Address - Zip Code:05465-2100
Mailing Address - Country:US
Mailing Address - Phone:802-899-3973
Mailing Address - Fax:
Practice Address - Street 1:22 RACEWAY RD
Practice Address - Street 2:
Practice Address - City:JERICHO
Practice Address - State:VT
Practice Address - Zip Code:05465-2100
Practice Address - Country:US
Practice Address - Phone:802-899-3973
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-03-29
Last Update Date:2023-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
VT016.0134207122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program