Provider Demographics
NPI:1154484228
Name:SHARON COBHAM DDS AND NICOLE LECANN DDS IV PA
Entity Type:Organization
Organization Name:SHARON COBHAM DDS AND NICOLE LECANN DDS IV PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:NICOLE
Authorized Official - Middle Name:
Authorized Official - Last Name:LECANN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:919-789-8682
Mailing Address - Street 1:4814 SIX FORKS RD
Mailing Address - Street 2:SUITE 102
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27609
Mailing Address - Country:US
Mailing Address - Phone:919-783-5550
Mailing Address - Fax:919-791-1990
Practice Address - Street 1:4814 SIX FORKS RD
Practice Address - Street 2:SUITE 102
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27609
Practice Address - Country:US
Practice Address - Phone:919-783-5550
Practice Address - Fax:919-791-1990
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-19
Last Update Date:2008-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC69701223G0001X
NC70001223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC89014NTMedicaid
NC014NTOtherNCHC