Organization
M. STACY COOK, DMD
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MRS. STACY WILSON (OFFICE MANAGER)
(601) 394-2467
Entity
Organization
Contact information
Practice address
403 MAIN ST, LEAKESVILLE, MS 39451
(601) 394-2467
(601) 394-2468
Mailing address
PO BOX 280, LEAKESVILLE, MS 39451-0280
(601) 394-2467
(601) 394-2468
Taxonomy
Speciality
Code
Description
License number
State
122300000X
Dentist
Primary
2870 95
MS
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
09015334
—
MS
01
—
425495231B
BCBS OF MS
MS
01
—
73003671
BCBS AL
AL
Enumeration date
05/22/2007
Last updated
04/25/2012
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