Provider Demographics
NPI:1548713092
Name:CLIFFORD J COOK DMD PA
Entity type:Organization
Organization Name:CLIFFORD J COOK DMD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CLIFFORD
Authorized Official - Middle Name:J
Authorized Official - Last Name:COOK
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:228-388-3353
Mailing Address - Street 1:10437 LAMEY BRIDGE RD
Mailing Address - Street 2:STE E
Mailing Address - City:DIBERVILLE
Mailing Address - State:MS
Mailing Address - Zip Code:39540-2709
Mailing Address - Country:US
Mailing Address - Phone:228-860-7895
Mailing Address - Fax:
Practice Address - Street 1:10437 LAMEY BRIDGE RD
Practice Address - Street 2:STE E
Practice Address - City:DIBERVILLE
Practice Address - State:MS
Practice Address - Zip Code:39540-2709
Practice Address - Country:US
Practice Address - Phone:228-860-7895
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-08-02
Last Update Date:2017-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty