Provider Demographics
NPI:1275016263
Name:R.E. OFFUTT, DDS, MS AND B.L. COCKERHAM DDS, MSP, PLLC
Entity Type:Organization
Organization Name:R.E. OFFUTT, DDS, MS AND B.L. COCKERHAM DDS, MSP, PLLC
Other - Org Name:FORT MILL PERIODONTICS & IMPLANT DENTISTRY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:
Authorized Official - Last Name:OFFUTT
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:704-366-2774
Mailing Address - Street 1:6719 FAIRVIEW ROAD
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28210
Mailing Address - Country:US
Mailing Address - Phone:704-366-2774
Mailing Address - Fax:704-366-2639
Practice Address - Street 1:929 MARKET ST
Practice Address - Street 2:
Practice Address - City:FORT MILL
Practice Address - State:SC
Practice Address - Zip Code:29708
Practice Address - Country:US
Practice Address - Phone:803-547-0304
Practice Address - Fax:704-366-2639
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-09-14
Last Update Date:2018-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0300XDental ProvidersDentistPeriodonticsGroup - Multi-Specialty