Healthcare Provider Details

I. General information

NPI: 1104222173
Provider Name (Legal Business Name): CHARLES COOPER JR.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/18/2014
Last Update Date: 11/18/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3200 S KINGS HWY
CUSHING OK
74023-5355
US

IV. Provider business mailing address

3200 S KINGS HWY
CUSHING OK
74023-5355
US

V. Phone/Fax

Practice location:
  • Phone: 918-225-3336
  • Fax: 918-223-2937
Mailing address:
  • Phone: 918-225-3336
  • Fax: 918-223-2937

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number5163
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: