Healthcare Provider Details

I. General information

NPI: 1417123456
Provider Name (Legal Business Name): DANIEL R COOK D.D.S., M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/30/2008
Last Update Date: 02/04/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

130 LAKE CONCORD RD
CONCORD NC
28025
US

IV. Provider business mailing address

130 LAKE CONCORD RD.
CONCORD NC
28025
US

V. Phone/Fax

Practice location:
  • Phone: 504-913-4788
  • Fax:
Mailing address:
  • Phone: 704-788-1192
  • Fax: 704-788-1178

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberS-407
License Number StateLA
# 2
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number8069
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: