MEDICARE: DR. STEPHEN A COOK DDS MSD

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	1223P0300X	Periodontics	12007594	IN

General Provider Information

NPI Number	:	1598803777
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. STEPHEN A COOK DDS MSD

Provider Business Mailing Address
First Line	:	2114 SCOTT ST
Second Line	:
City	:	LAFAYETTE
State	:	IN
Zip	:	47904-2932
Country	:	US
Telephone Number	:	765-448-1539
Fax Number	:	765-447-6388

Provider Business Practice Location Address
First Line	:	2114 SCOTT ST
Second Line	:
City	:	LAFAYETTE
State	:	IN
Zip	:	47904-2932
Country	:	US
Telephone Number	:	765-448-1539
Fax Number	:	765-447-6388

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

Provider Enumeration Date	:	02/01/2007
Last Update Date	:	07/08/2007

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