MEDICARE: DR. JUSTIN MICHAEL COOPER DDS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	4436	AR

General Provider Information

NPI Number	:	1215545710
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JUSTIN MICHAEL COOPER DDS

Provider Business Mailing Address
First Line	:	1400 MEADOW BRIDGE DR
Second Line	:
City	:	GREENWOOD
State	:	AR
Zip	:	72936-3059
Country	:	US
Telephone Number	:	479-996-6736
Fax Number	:

Provider Business Practice Location Address
First Line	:	5008 S U ST STE 101A
Second Line	:
City	:	FORT SMITH
State	:	AR
Zip	:	72903-3613
Country	:	US
Telephone Number	:	479-431-2527
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/21/2020
Last Update Date	:	07/21/2020

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