Healthcare Provider Details

I. General information

NPI: 1073722203
Provider Name (Legal Business Name): M. STACY COOK, DMD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/22/2007
Last Update Date: 04/25/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

403 MAIN ST
LEAKESVILLE MS
39451
US

IV. Provider business mailing address

PO BOX 280
LEAKESVILLE MS
39451-0280
US

V. Phone/Fax

Practice location:
  • Phone: 601-394-2467
  • Fax: 601-394-2468
Mailing address:
  • Phone: 601-394-2467
  • Fax: 601-394-2468

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number2870 95
License Number StateMS

VIII. Authorized Official

Name: MRS. STACY WILSON
Title or Position: OFFICE MANAGER
Credential:
Phone: 601-394-2467