Provider Demographics
NPI:1568502516
Name:COBURN, MARIANNE LUCILLE (DDS)
Entity Type:Individual
Prefix:DR
First Name:MARIANNE
Middle Name:LUCILLE
Last Name:COBURN
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3110 COUNTRY CLUB LN
Mailing Address - Street 2:
Mailing Address - City:HURON
Mailing Address - State:OH
Mailing Address - Zip Code:44839-1080
Mailing Address - Country:US
Mailing Address - Phone:419-625-4191
Mailing Address - Fax:
Practice Address - Street 1:1221 HAYES AVE
Practice Address - Street 2:SUITE C
Practice Address - City:SANDUSKY
Practice Address - State:OH
Practice Address - Zip Code:44870-3345
Practice Address - Country:US
Practice Address - Phone:419-627-8131
Practice Address - Fax:419-621-1773
Is Sole Proprietor?:No
Enumeration Date:2007-02-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH30-0159521223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0645814Medicaid
OH0645814Medicaid
OHT48356Medicare UPIN