MEDICARE: MICHAEL W. COOPER, D.D.S., P.A.

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	2569	AR

General Provider Information

NPI Number	:	1518038728
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MICHAEL W. COOPER, D.D.S., P.A.

Provider Business Mailing Address
First Line	:	110 S INGLEWOOD AVE
Second Line	:
City	:	RUSSELLVILLE
State	:	AR
Zip	:	72801-3353
Country	:	US
Telephone Number	:	479-968-4477
Fax Number	:	479-968-4498

Provider Business Practice Location Address
First Line	:	110 S INGLEWOOD AVE
Second Line	:
City	:	RUSSELLVILLE
State	:	AR
Zip	:	72801-3353
Country	:	US
Telephone Number	:	479-968-4477
Fax Number	:	479-968-4498

Authorized Official
Title or Position	:	OWNER
Name	:	DR. MICHAEL W. COOPER
Credential	:	D.D.S.
Telephone Number	:	479-968-4477

Provider Enumeration Date	:	11/10/2006
Last Update Date	:	08/22/2020

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