MEDICARE: DR. ELIZABETH JOAN COOPER DDS

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	122300000X	Dentist	9326	MN

General Provider Information

NPI Number	:	1538172929
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. ELIZABETH JOAN COOPER DDS

Provider Business Mailing Address
First Line	:	757 CLEVELAND AVE S
Second Line	:
City	:	SAINT PAUL
State	:	MN
Zip	:	55116-1302
Country	:	US
Telephone Number	:	651-699-1547
Fax Number	:	651-690-0164

Provider Business Practice Location Address
First Line	:	757 CLEVELAND AVE S
Second Line	:
City	:	SAINT PAUL
State	:	MN
Zip	:	55116-1302
Country	:	US
Telephone Number	:	651-699-1547
Fax Number	:	651-690-0164

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

Provider Enumeration Date	:	08/15/2006
Last Update Date	:	07/08/2007

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