Healthcare Provider Details

I. General information

NPI: 1982650404
Provider Name (Legal Business Name): VICTOR D COOK DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 05/26/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7910 USTICK RD
BOISE ID
83704-5850
US

IV. Provider business mailing address

7910 USTICK RD
BOISE ID
83704-5850
US

V. Phone/Fax

Practice location:
  • Phone: 208-322-5522
  • Fax:
Mailing address:
  • Phone: 208-322-5522
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberD1550-05
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: