=====================================================
General NPI Number Information
=====================================================
NPI Number | 1912994914
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ANGELA M COOPER DDS
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/04/2005
-----------------------------------------------------
Last Update Date | 10/15/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1514 1ST ST N
-----------------------------------------------------
City | WINTER HAVEN
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33881-2476
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 866-234-8534
-----------------------------------------------------
Fax | 863-292-4293
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 47 5TH ST NW
-----------------------------------------------------
City | WINTER HAVEN
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33881-4672
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 863-291-5110
-----------------------------------------------------
Fax | 863-291-5128
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223D0001X
-----------------------------------------------------
Taxonomy Name | Public Health Dentistry
-----------------------------------------------------
License Number | DN13255
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------