Healthcare Provider Details

I. General information

NPI: 1386249829
Provider Name (Legal Business Name): KEITH M COOPER DDS INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/02/2020
Last Update Date: 12/02/2020
Certification Date: 12/02/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5150 GRAVES AVE STE 12E
SAN JOSE CA
95129-5015
US

IV. Provider business mailing address

5150 GRAVES AVE STE 12E
SAN JOSE CA
95129-5015
US

V. Phone/Fax

Practice location:
  • Phone: 408-253-4150
  • Fax: 408-253-1979
Mailing address:
  • Phone: 408-253-4150
  • Fax: 408-253-1979

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0700X
TaxonomyProsthodontics
License Number
License Number State

VIII. Authorized Official

Name: KIETH COOPER
Title or Position: OWNER
Credential: DDS
Phone: 408-253-4150