Healthcare Provider Details

I. General information

NPI: 1043335276
Provider Name (Legal Business Name): LYNDON COOPER DDS, MS, PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/20/2007
Last Update Date: 01/14/2020
Certification Date: 01/14/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

801 S PAULINA ST # 402E
CHICAGO IL
60612-7210
US

IV. Provider business mailing address

415 E NORTH WATER ST APT 607
CHICAGO IL
60611-5613
US

V. Phone/Fax

Practice location:
  • Phone: 312-996-7515
  • Fax:
Mailing address:
  • Phone: 919-649-7531
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0700X
TaxonomyProsthodontics
License Number021.002815
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number019.030537
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code1223P0700X
TaxonomyProsthodontics
License Number38430-1
License Number StateNY
# 4
Primary TaxonomyN
Taxonomy Code1223P0700X
TaxonomyProsthodontics
License Number0007
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: