Provider Demographics
NPI:1558634808
Name:DR. JERRY E. COHRON PLLC
Entity Type:Organization
Organization Name:DR. JERRY E. COHRON PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:ELISHA
Authorized Official - Middle Name:D
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:270-745-0698
Mailing Address - Street 1:948 ELM ST
Mailing Address - Street 2:SUITE 2
Mailing Address - City:BOWLING GREEN
Mailing Address - State:KY
Mailing Address - Zip Code:42101-2277
Mailing Address - Country:US
Mailing Address - Phone:270-745-0698
Mailing Address - Fax:270-745-0067
Practice Address - Street 1:948 ELM ST
Practice Address - Street 2:SUITE 2
Practice Address - City:BOWLING GREEN
Practice Address - State:KY
Practice Address - Zip Code:42101-2277
Practice Address - Country:US
Practice Address - Phone:270-745-0698
Practice Address - Fax:270-745-0067
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-02-17
Last Update Date:2012-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY4043122300000X, 1223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
No122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY60040433Medicaid
KY64040439Medicaid