Organization Name: | COBURN DENTAL OFFICE LLC |
NPI Number: | 1770831539 |
Entity Type Code: | Organizational (2) |
Authorized Official Name: | RICHARD RYAN COBURN (OWNER) |
Mailing Address: | 116 N Meade Ave Glendive |
State: | MT US |
Postal Code: | 593301604 |
Phone Number: | 4063778265 |
Fax Number: | 4063778267 |
NPI Enumeration Date: | 08/27/2012 |
NPI Last Update Date: | 11/23/2015 |
Replacement NPI: | 0 |
NPI Deactivation Date: | |
NPI Reactivation Date: |
Taxonomy Information: | |
Healthcare Provider Taxonomy: | 261QD0000X |
License Number: | 2288 |
Healthcare Provider Taxonomy: (Secondary) | Y |
State: | MT |
Taxonomy Type: | Ambulatory Health Care Facilities |
Taxonomy Classification: | Clinic/Center |
Taxonomy Specialization: | Dental |
Taxonomy Definition: |