Provider Demographics
NPI:1417636945
Name:COBERLY, STACI RENE (RDH)
Entity Type:Individual
Prefix:
First Name:STACI
Middle Name:RENE
Last Name:COBERLY
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1203 D ST
Mailing Address - Street 2:
Mailing Address - City:SALIDA
Mailing Address - State:CO
Mailing Address - Zip Code:81201-2742
Mailing Address - Country:US
Mailing Address - Phone:785-443-1707
Mailing Address - Fax:
Practice Address - Street 1:1203 D ST
Practice Address - Street 2:
Practice Address - City:SALIDA
Practice Address - State:CO
Practice Address - Zip Code:81201-2742
Practice Address - Country:US
Practice Address - Phone:785-443-1707
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-12
Last Update Date:2023-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CODH.000904674124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist