MEDICARE: JONATHAN TODD COOK 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	122300000X	Dentist	D7453	OR

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1275610495	OTHER	OR	BUSINESS NPI #

General Provider Information

NPI Number	:	1366694549
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JONATHAN TODD COOK DDS

Provider Business Mailing Address
First Line	:	1001 MOLALLA AVE
Second Line	:	SUITE 110
City	:	OREGON CITY
State	:	OR
Zip	:	97045-3788
Country	:	US
Telephone Number	:	503-656-8287
Fax Number	:	503-656-8375

Provider Business Practice Location Address
First Line	:	1001 MOLALLA AVE
Second Line	:	SUITE 110
City	:	OREGON CITY
State	:	OR
Zip	:	97045-3788
Country	:	US
Telephone Number	:	503-656-8287
Fax Number	:	503-656-8375

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

Provider Enumeration Date	:	10/19/2008
Last Update Date	:	10/19/2008

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