=====================================================
General NPI Number Information
=====================================================
NPI Number | 1750759494
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | JOHN E. COOPER, D.D.S.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/11/2015
-----------------------------------------------------
Last Update Date | 09/11/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 11126 W WISCONSIN AVE SUITE 1
-----------------------------------------------------
City | YOUNGTOWN
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85363-1068
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 623-933-3684
-----------------------------------------------------
Fax | 623-933-1226
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 11126 W WISCONSIN AVE SUITE 1
-----------------------------------------------------
City | YOUNGTOWN
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85363-1068
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 623-933-3684
-----------------------------------------------------
Fax | 623-933-1226
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | JOHN E COOPER II
-----------------------------------------------------
Credential | D.D.S.
-----------------------------------------------------
Telephone | 623-933-3684
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | D2710
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------