Healthcare Provider Details

I. General information

NPI: 1265509319
Provider Name (Legal Business Name): JOHN E COOPER II DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/30/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11126 WEST WISCONSIN AVENUE SUITE 1
YOUNGTOWN AZ
85363
US

IV. Provider business mailing address

11126 WEST WISCONSIN AVENUE SUITE 1
YOUNGTOWN AZ
85363
US

V. Phone/Fax

Practice location:
  • Phone: 823-933-3684
  • Fax: 623-933-1226
Mailing address:
  • Phone: 823-933-3684
  • Fax: 623-933-1226

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number2710
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: