Provider Demographics
NPI:1114233533
Name:COBB, JEREMY (DDS)
Entity Type:Individual
Prefix:
First Name:JEREMY
Middle Name:
Last Name:COBB
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1830 BLANKENSHIP RD
Mailing Address - Street 2:SUITE 225
Mailing Address - City:WEST LINN
Mailing Address - State:OR
Mailing Address - Zip Code:97068-4181
Mailing Address - Country:US
Mailing Address - Phone:503-722-2006
Mailing Address - Fax:
Practice Address - Street 1:1830 BLANKENSHIP RD
Practice Address - Street 2:SUITE 225
Practice Address - City:WEST LINN
Practice Address - State:OR
Practice Address - Zip Code:97068-4181
Practice Address - Country:US
Practice Address - Phone:503-722-2006
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-23
Last Update Date:2013-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD9504122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist