=====================================================
General NPI Number Information
=====================================================
NPI Number | 1063083145
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | STEVEN MICHAEL COOPER DMD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/08/2021
-----------------------------------------------------
Last Update Date | 07/08/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8253 W THUNDERBIRD RD STE 101
-----------------------------------------------------
City | PEORIA
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85381-4616
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 623-759-7656
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 201 MERRIL MARTIN RD
-----------------------------------------------------
City | SAGLE
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83860-9104
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-610-8553
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | D011105
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------