Healthcare Provider Details

I. General information

NPI: 1790812063
Provider Name (Legal Business Name): PHYLLIS B. COOK, DDS, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/27/2007
Last Update Date: 02/28/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7028 WRIGHTSVILLE AVE
WILMINGTON NC
28403-3655
US

IV. Provider business mailing address

7028 WRIGHTSVILLE AVE
WILMINGTON NC
28403-3655
US

V. Phone/Fax

Practice location:
  • Phone: 910-256-8486
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number6551
License Number StateNC

VIII. Authorized Official

Name: PHYLLIS COOK
Title or Position: PRESIDENT-OWNER
Credential:
Phone: 910-256-8486