Healthcare Provider Details

I. General information

NPI: 1598803777
Provider Name (Legal Business Name): STEPHEN A COOK DDS MSD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/01/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2114 SCOTT ST
LAFAYETTE IN
47904-2932
US

IV. Provider business mailing address

2114 SCOTT ST
LAFAYETTE IN
47904-2932
US

V. Phone/Fax

Practice location:
  • Phone: 765-448-1539
  • Fax: 765-447-6388
Mailing address:
  • Phone: 765-448-1539
  • Fax: 765-447-6388

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number12007594
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: