MEDICARE: DR. HOLLY L COOK 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	36741	CA

General Provider Information

NPI Number	:	1184780173
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. HOLLY L COOK D.D.S.

Provider Business Mailing Address
First Line	:	2229 BARTON AVE
Second Line	:
City	:	SOUTH LAKE TAHOE
State	:	CA
Zip	:	96150-3411
Country	:	US
Telephone Number	:	530-541-7862
Fax Number	:	530-541-7863

Provider Business Practice Location Address
First Line	:	2229 BARTON AVE
Second Line	:
City	:	SO. LAKE TAHOE
State	:	CA
Zip	:	96150-3411
Country	:	US
Telephone Number	:	530-541-7862
Fax Number	:	530-541-7863

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

Provider Enumeration Date	:	12/28/2006
Last Update Date	:	07/08/2007

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