Provider Demographics
NPI:1225582596
Name:B.L. COCKERHAM III & ASSOCIATES PLLC
Entity Type:Organization
Organization Name:B.L. COCKERHAM III & ASSOCIATES PLLC
Other - Org Name:SOUTHPARK PERIODONTICS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BOBBY
Authorized Official - Middle Name:L
Authorized Official - Last Name:COCKERHAM
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:704-366-2774
Mailing Address - Street 1:6719 FAIRVIEW RD
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28210-3879
Mailing Address - Country:US
Mailing Address - Phone:704-366-2774
Mailing Address - Fax:704-366-2639
Practice Address - Street 1:6719 FAIRVIEW RD
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28210-3879
Practice Address - Country:US
Practice Address - Phone:704-366-2774
Practice Address - Fax:704-366-2639
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-08-04
Last Update Date:2023-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC46731223P0300X
NC91241223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0300XDental ProvidersDentistPeriodonticsGroup - Single Specialty