Healthcare Provider Details

I. General information

NPI: 1740353291
Provider Name (Legal Business Name): COOPER CALLAWAY DMD MS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/15/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 STARR AVE STE D
STARKVILLE MS
39759
US

IV. Provider business mailing address

100 STARR AVE STE D
STARKVILLE MS
39759
US

V. Phone/Fax

Practice location:
  • Phone: 662-615-4225
  • Fax: 662-615-4288
Mailing address:
  • Phone: 662-615-4225
  • Fax: 662-615-4288

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number2991 97
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: