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General NPI Number Information
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NPI Number | 1134339500
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Entity Type | Organization
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Legal Business Name | FOX RIVER PERIODONTICS SC
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Dates
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Enumeration Date | 05/23/2007
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 2557B EAST CALUMET ST
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City | APPLETON
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State | WI
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Zip | 54915
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Country | US
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Telephone | 920-733-7770
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Fax | 920-733-7798
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Provider Business Mailing Address
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Address Line | 2557B EAST CALUMET ST
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City | APPLETON
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State | WI
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Zip | 54915
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Country | US
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Telephone | 920-733-7770
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Fax | 920-733-7798
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. JASON WILLIAM COOKE
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Credential | DDS,MS
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Telephone | 920-733-7770
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223P0300X
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Taxonomy Name | Periodontics
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License Number | 5864-015
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License Number State | WI
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