MEDICARE: TODD C 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	204E00000X	Oral & Maxillofacial Surgery (D.M.D.)	9520	WA
2	204E00000X	Oral & Maxillofacial Surgery (D.M.D.)	D9191	OR
3	1223S0112X	Oral and Maxillofacial Surgery (Dentist)	9520	WA
4	1223S0112X	Oral and Maxillofacial Surgery (Dentist)	D9191	OR

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1871523183
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TODD C COOPER DDS

Provider Business Mailing Address
First Line	:	512 N YOUNG ST
Second Line	:
City	:	KENNEWICK
State	:	WA
Zip	:	99336-7806
Country	:	US
Telephone Number	:	509-783-7600
Fax Number	:	509-783-0774

Provider Business Practice Location Address
First Line	:	512 N YOUNG ST
Second Line	:
City	:	KENNEWICK
State	:	WA
Zip	:	99336-7806
Country	:	US
Telephone Number	:	509-783-7600
Fax Number	:	509-783-0774

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

Provider Enumeration Date	:	07/03/2006
Last Update Date	:	11/25/2014

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Directions to “ TODD C COOPER DDS” Practice Location

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