MEDICARE: COOPER OWENS DDS LLC

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

General Provider Information

NPI Number	:	1407718075
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	COOPER OWENS DDS LLC

Provider Business Mailing Address
First Line	:	220 E MAIN ST
Second Line	:
City	:	GENEVA
State	:	OH
Zip	:	44041-1481
Country	:	US
Telephone Number	:	440-466-4884
Fax Number	:	330-319-7545

Provider Business Practice Location Address
First Line	:	220 E MAIN ST
Second Line	:
City	:	GENEVA
State	:	OH
Zip	:	44041-1481
Country	:	US
Telephone Number	:	440-466-4884
Fax Number	:	330-319-7545

Authorized Official
Title or Position	:	OWNER/DENTIST
Name	:	RUSSELL OWENS
Credential	:	DDS
Telephone Number	:	440-466-4884

Provider Enumeration Date	:	12/02/2025
Last Update Date	:	12/02/2025

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