MEDICARE: COREY COOPER

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	126800000X	Dental Assistant		AL

General Provider Information

NPI Number	:	1427636299
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	COREY COOPER

Provider Business Mailing Address
First Line	:	290 MARTIN LUTHER KING JR DR SE UNIT 1012
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30312-2525
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	290 MARTIN LUTHER KING JR DR SE UNIT 1012
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30312-2525
Country	:	US
Telephone Number	:	833-878-3567
Fax Number	:

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

Provider Enumeration Date	:	03/31/2021
Last Update Date	:	03/31/2021

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Directions to “ COREY COOPER ” Practice Location

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