Healthcare Provider Details

I. General information

NPI: 1598558207
Provider Name (Legal Business Name): SHANE MICHAEL COOLEY DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/26/2025
Last Update Date: 07/30/2026
Certification Date: 07/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1320 MERCY DR NW
CANTON OH
44708-2614
US

IV. Provider business mailing address

1407 CHANTILLY CIR NE
CANTON OH
44721-3914
US

V. Phone/Fax

Practice location:
  • Phone: 330-489-1000
  • Fax:
Mailing address:
  • Phone: 330-354-9566
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number8242
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: