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General NPI Number Information
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NPI Number | 1457716870
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Entity Type | Organization
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Legal Business Name | WAYNE COOK DENTISRTY LLC
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Dates
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Enumeration Date | 12/30/2015
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Last Update Date | 12/30/2015
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Provider Practice Location Address
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Address Line | 303 BANCARIO STE 7
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City | MARION
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State | AR
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Zip | 72364-2826
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Country | US
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Telephone | 870-739-8799
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Fax | 870-739-8675
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Provider Business Mailing Address
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Address Line | 303 BANCARIO STE 7
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City | MARION
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State | AR
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Zip | 72364-2826
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Country | US
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Telephone | 870-739-8799
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Fax | 870-739-8675
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Authorized Official
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Title or Position | OWNER
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Name | DR. JERRY WAYNE COOK JR.
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Credential | D.D.S.
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Telephone | 870-739-8799
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QD0000X
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Taxonomy Name | Dental Clinic/Center
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License Number | 3113
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License Number State | AR
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