MEDICARE: DR. MICHAEL 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	2569	AR

General Provider Information

NPI Number	:	1073775045
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MICHAEL W. COOPER D.D.S.

Provider Business Mailing Address
First Line	:	110 S INGLEWOOD AVE
Second Line	:
City	:	RUSSELLVILLE
State	:	AR
Zip	:	72801-3353
Country	:	US
Telephone Number	:	479-968-4477
Fax Number	:

Provider Business Practice Location Address
First Line	:	110 S INGLEWOOD AVE
Second Line	:
City	:	RUSSELLVILLE
State	:	AR
Zip	:	72801-3353
Country	:	US
Telephone Number	:	479-968-4477
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/30/2008
Last Update Date	:	06/30/2008

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