Provider Demographics
NPI:1568654150
Name:COBURN, JOHN D (DMD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:D
Last Name:COBURN
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:700 W IRONWOOD DR
Mailing Address - Street 2:STE 241
Mailing Address - City:COEUR D ALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83814-2656
Mailing Address - Country:US
Mailing Address - Phone:208-664-4831
Mailing Address - Fax:208-666-1804
Practice Address - Street 1:700 W IRONWOOD DR
Practice Address - Street 2:STE 241
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83814-2656
Practice Address - Country:US
Practice Address - Phone:208-664-4831
Practice Address - Fax:208-666-1804
Is Sole Proprietor?:No
Enumeration Date:2007-08-16
Last Update Date:2014-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD41881223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice