Healthcare Provider Details

I. General information

NPI: 1770853285
Provider Name (Legal Business Name): SEAN P. COONEY, DMD, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/01/2012
Last Update Date: 01/01/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30 FENTON PLZ
FENTON MO
63026-4110
US

IV. Provider business mailing address

30 FENTON PLZ
FENTON MO
63026-4110
US

V. Phone/Fax

Practice location:
  • Phone: 636-349-0070
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number2005018812
License Number StateMO

VIII. Authorized Official

Name: DR. SEAN COONEY
Title or Position: OWNER
Credential: DMD
Phone: 636-349-0070