=====================================================
General NPI Number Information
=====================================================
NPI Number | 1346263613
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LOREN S COOK DMD PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/26/2006
-----------------------------------------------------
Last Update Date | 12/23/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 611 S MAIN STREET STE A
-----------------------------------------------------
City | BLACKSBURG
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 24060-5208
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 540-951-8383
-----------------------------------------------------
Fax | 540-953-5030
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 611 S MAIN STREET STE A
-----------------------------------------------------
City | BLACKSBURG
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 24060-5208
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 540-951-8383
-----------------------------------------------------
Fax | 540-953-5030
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DENTIST/OWNER/PRESIDENT
-----------------------------------------------------
Name | MRS. LOREN S. COOK
-----------------------------------------------------
Credential | DMD
-----------------------------------------------------
Telephone | 540-951-8383
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 401006217
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 0401006217
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 0401412653
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 0401412480
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------