Provider Demographics
NPI:1043335276
Name:COOPER, LYNDON (DDS, MS, PHD)
Entity type:Individual
Prefix:DR
First Name:LYNDON
Middle Name:
Last Name:COOPER
Suffix:
Gender:M
Credentials:DDS, MS, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:415 E NORTH WATER ST APT 607
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60611-5613
Mailing Address - Country:US
Mailing Address - Phone:919-649-7531
Mailing Address - Fax:
Practice Address - Street 1:801 S PAULINA ST # 402E
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60612-7210
Practice Address - Country:US
Practice Address - Phone:312-996-7515
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-20
Last Update Date:2020-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL021.0028151223P0700X
IL019.0305371223G0001X
NY38430-11223P0700X
NC00071223P0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0700XDental ProvidersDentistProsthodontics
No1223G0001XDental ProvidersDentistGeneral Practice