MEDICARE: MIKE D 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	13733	TX

General Provider Information

NPI Number	:	1992891113
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MIKE D COOK DDS

Provider Business Mailing Address
First Line	:	1300 W MAGNOLIA AVE
Second Line	:
City	:	FT WORTH
State	:	TX
Zip	:	76104-4340
Country	:	US
Telephone Number	:	817-877-0737
Fax Number	:	817-877-0737

Provider Business Practice Location Address
First Line	:	1300 W MAGNOLIA AVE
Second Line	:
City	:	FT WORTH
State	:	TX
Zip	:	76104-4340
Country	:	US
Telephone Number	:	817-877-0737
Fax Number	:	817-877-0737

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

Provider Enumeration Date	:	10/05/2006
Last Update Date	:	07/08/2007

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