Healthcare Provider Details

I. General information

NPI: 1770398729
Provider Name (Legal Business Name): CHARLIE GLENN COOK II DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/07/2025
Last Update Date: 07/24/2026
Certification Date: 07/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

845 S HIGHLAND ST
MEMPHIS TN
38111-4254
US

IV. Provider business mailing address

845 S HIGHLAND ST
MEMPHIS TN
38111-4254
US

V. Phone/Fax

Practice location:
  • Phone: 901-323-8488
  • Fax: 901-323-8489
Mailing address:
  • Phone: 901-323-8488
  • Fax: 901-323-8489

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number12967
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: