Healthcare Provider Details

I. General information

NPI: 1396897138
Provider Name (Legal Business Name): JASON RYAN COOMER DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/18/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

203 S DIXIE HWY
CAVE CITY KY
42127-8866
US

IV. Provider business mailing address

203 S DIXIE HWY
CAVE CITY KY
42127-8866
US

V. Phone/Fax

Practice location:
  • Phone: 270-773-3943
  • Fax: 270-773-3944
Mailing address:
  • Phone: 270-773-3943
  • Fax: 270-773-3944

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number7869
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: