MEDICARE: E.W. COOPER D.D.S

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	TN 3275	TN

General Provider Information

NPI Number	:	1063718724
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	E.W. COOPER D.D.S

Provider Business Mailing Address
First Line	:	515 EAST WATAUGA AVE
Second Line	:
City	:	JOHNSON CITY
State	:	TN
Zip	:	37601-4038
Country	:	US
Telephone Number	:	423-928-2621
Fax Number	:

Provider Business Practice Location Address
First Line	:	515 E WATAUGA AVE
Second Line	:
City	:	JOHNSON CITY
State	:	TN
Zip	:	37601-4038
Country	:	US
Telephone Number	:	423-928-2621
Fax Number	:

Authorized Official
Title or Position	:	DENTIST
Name	:	ERNEST W COOPER
Credential	:
Telephone Number	:	423-928-2621

Provider Enumeration Date	:	01/28/2011
Last Update Date	:	01/28/2011

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