Healthcare Provider Details

I. General information

NPI: 1447366513
Provider Name (Legal Business Name): GARY ALAN COOPER DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/22/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

420 S CHARLES G SEIVERS BLVD
CLINTON TN
37716-3931
US

IV. Provider business mailing address

420 S CHARLES G SEIVERS BLVD
CLINTON TN
37716-3931
US

V. Phone/Fax

Practice location:
  • Phone: 865-457-1496
  • Fax: 865-457-4336
Mailing address:
  • Phone: 865-457-1496
  • Fax: 865-457-4336

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDS4785
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: