Provider Demographics
NPI:1114303955
Name:AMANDA COBB, D.M.D., PLLC
Entity Type:Organization
Organization Name:AMANDA COBB, D.M.D., PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:AMANDA
Authorized Official - Middle Name:
Authorized Official - Last Name:COBB
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:386-672-6581
Mailing Address - Street 1:785 W GRANADA BLVD
Mailing Address - Street 2:SUITE 3
Mailing Address - City:ORMOND BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32174-9522
Mailing Address - Country:US
Mailing Address - Phone:386-672-6581
Mailing Address - Fax:
Practice Address - Street 1:785 W GRANADA BLVD
Practice Address - Street 2:SUITE 3
Practice Address - City:ORMOND BEACH
Practice Address - State:FL
Practice Address - Zip Code:32174-9522
Practice Address - Country:US
Practice Address - Phone:386-672-6581
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-08-04
Last Update Date:2015-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN201191223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty