Provider Demographics
NPI:1053423731
Name:COOPER, GEORGE R (DDS)
Entity type:Individual
Prefix:DR
First Name:GEORGE
Middle Name:R
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 1:2121 E. DUPONT ROAD
Mailing Address - Street 2:SUITE E
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46845
Mailing Address - Country:US
Mailing Address - Phone:260-489-1508
Mailing Address - Fax:260-489-9760
Practice Address - Street 1:2121 E. DUPONT ROAD
Practice Address - Street 2:SUITE E
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46845
Practice Address - Country:US
Practice Address - Phone:260-489-1508
Practice Address - Fax:260-489-9760
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2022-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN120083791223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice