Provider Demographics
NPI:1447366885
Name:COOPER, KEITH D (DDS)
Entity type:Individual
Prefix:DR
First Name:KEITH
Middle Name:D
Last Name:COOPER
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:12 S JACKSON ST
Mailing Address - Street 2:
Mailing Address - City:PERRYVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:63775-2515
Mailing Address - Country:US
Mailing Address - Phone:573-547-6520
Mailing Address - Fax:573-547-8272
Practice Address - Street 1:12 S JACKSON ST
Practice Address - Street 2:
Practice Address - City:PERRYVILLE
Practice Address - State:MO
Practice Address - Zip Code:63775-2515
Practice Address - Country:US
Practice Address - Phone:573-547-6520
Practice Address - Fax:573-547-8272
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MODE0158241223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1582048OtherUNITED CONCORDIA