Healthcare Provider Details

I. General information

NPI: 1750759494
Provider Name (Legal Business Name): JOHN E. COOPER, D.D.S.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/11/2015
Last Update Date: 09/11/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11126 W WISCONSIN AVE SUITE 1
YOUNGTOWN AZ
85363-1068
US

IV. Provider business mailing address

11126 W WISCONSIN AVE SUITE 1
YOUNGTOWN AZ
85363-1068
US

V. Phone/Fax

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

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberD2710
License Number StateAZ

VIII. Authorized Official

Name: JOHN E COOPER II
Title or Position: PRESIDENT
Credential: D.D.S.
Phone: 623-933-3684