MEDICARE: DAVID MICHAEL 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		IL

General Provider Information

NPI Number	:	1720086531
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DAVID MICHAEL COOK D.D.S.

Provider Business Mailing Address
First Line	:	PO BOX 253
Second Line	:	410 W. POPLAR ST.
City	:	HARRISBURG
State	:	IL
Zip	:	62946-0253
Country	:	US
Telephone Number	:	618-252-8333
Fax Number	:	618-252-8333

Provider Business Practice Location Address
First Line	:	410 W POPLAR ST
Second Line	:
City	:	HARRISBURG
State	:	IL
Zip	:	62946-1426
Country	:	US
Telephone Number	:	618-252-8333
Fax Number	:	618-252-8333

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

Provider Enumeration Date	:	07/14/2005
Last Update Date	:	07/08/2007

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