Healthcare Provider Details

I. General information

NPI: 1801901004
Provider Name (Legal Business Name): MATTHEW KELLEY COOK DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/20/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

218 FRONT ST
OWEGO NY
13827
US

IV. Provider business mailing address

218 FRONT ST
OWEGO NY
13827
US

V. Phone/Fax

Practice location:
  • Phone: 607-687-4522
  • Fax: 607-687-0750
Mailing address:
  • Phone: 607-687-4522
  • Fax: 607-687-0750

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number51736
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: