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General NPI Number Information
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NPI Number | 1134509813
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Entity Type | Individual
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Provider Name | MARY OLIVIA COOK DMD
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Gender | Female
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Dates
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Enumeration Date | 06/08/2015
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Last Update Date | 04/30/2019
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Provider Practice Location Address
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Address Line | 1 WOODGREEN PL STE 100
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City | MADISON
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State | MS
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Zip | 39110-8161
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Country | US
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Telephone | 601-605-5015
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Fax |
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Provider Business Mailing Address
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Address Line | 305 W 12TH AVE
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City | COLUMBUS
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State | OH
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Zip | 43210-1267
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 30.024519
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License Number State | OH
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Taxonomy #2
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Taxonomy Code | 1223E0200X
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Taxonomy Name | Endodontics
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License Number | ENDO-537-17
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License Number State | MS
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Taxonomy #3
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 3889-16
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License Number State | MS
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