Provider Demographics
NPI:1679978894
Name:COOPER CREEK DENTAL, LLC
Entity type:Organization
Organization Name:COOPER CREEK DENTAL, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:SHELLY
Authorized Official - Middle Name:DONEGAN
Authorized Official - Last Name:MCAVOY
Authorized Official - Suffix:
Authorized Official - Credentials:DME
Authorized Official - Phone:941-366-1010
Mailing Address - Street 1:8460 COOPER CREEK BLVD
Mailing Address - Street 2:SUITE 103
Mailing Address - City:UNIVERSITY PARK
Mailing Address - State:FL
Mailing Address - Zip Code:34201-2019
Mailing Address - Country:US
Mailing Address - Phone:941-366-1010
Mailing Address - Fax:941-355-5558
Practice Address - Street 1:8460 COOPER CREEK BLVD
Practice Address - Street 2:SUITE 103
Practice Address - City:UNIVERSITY PARK
Practice Address - State:FL
Practice Address - Zip Code:34201-2019
Practice Address - Country:US
Practice Address - Phone:941-366-1010
Practice Address - Fax:941-355-5558
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-10-30
Last Update Date:2014-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN16321122300000X
FLDN16999122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty