Provider Demographics
NPI:1174617450
Name:COOPER, JACK DEAN (DDS)
Entity type:Individual
Prefix:DR
First Name:JACK
Middle Name:DEAN
Last Name:COOPER
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:705 N 17TH AVE
Mailing Address - Street 2:
Mailing Address - City:ASHLAND
Mailing Address - State:NE
Mailing Address - Zip Code:68003
Mailing Address - Country:US
Mailing Address - Phone:402-944-3305
Mailing Address - Fax:402-944-3305
Practice Address - Street 1:705 N 17TH AVE
Practice Address - Street 2:
Practice Address - City:ASHLAND
Practice Address - State:NE
Practice Address - Zip Code:68003
Practice Address - Country:US
Practice Address - Phone:402-944-3305
Practice Address - Fax:402-944-3305
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE40051223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE47064558902Medicaid