Provider Demographics
NPI:1205012986
Name:COBB, STACEY ANN (HAP 200)
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:ANN
Last Name:COBB
Suffix:
Gender:F
Credentials:HAP 200
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20108 DOROTHY ST
Mailing Address - Street 2:
Mailing Address - City:CANYON COUNTRY
Mailing Address - State:CA
Mailing Address - Zip Code:91351-3804
Mailing Address - Country:US
Mailing Address - Phone:661-299-6602
Mailing Address - Fax:
Practice Address - Street 1:20108 DOROTHY ST
Practice Address - Street 2:
Practice Address - City:CANYON COUNTRY
Practice Address - State:CA
Practice Address - Zip Code:91351-3804
Practice Address - Country:US
Practice Address - Phone:661-299-6602
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-13
Last Update Date:2008-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAHAP 200124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist