Provider Demographics
NPI:1588196596
Name:MICHAEL R. COX D.D.S. P.L.L.C.
Entity Type:Organization
Organization Name:MICHAEL R. COX D.D.S. P.L.L.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MISS
Authorized Official - First Name:STEFANIE
Authorized Official - Middle Name:PHILLENA
Authorized Official - Last Name:GROGG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:304-485-7717
Mailing Address - Street 1:3705 EMERSON AVE
Mailing Address - Street 2:
Mailing Address - City:PARKERSBURG
Mailing Address - State:WV
Mailing Address - Zip Code:26104-1118
Mailing Address - Country:US
Mailing Address - Phone:304-485-7717
Mailing Address - Fax:304-428-4755
Practice Address - Street 1:3705 EMERSON AVE.
Practice Address - Street 2:
Practice Address - City:PARKERSBURG
Practice Address - State:WV
Practice Address - Zip Code:26104
Practice Address - Country:US
Practice Address - Phone:304-485-7717
Practice Address - Fax:304-428-4755
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-03-29
Last Update Date:2017-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV4123122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV4004033-000Medicaid
001464019OtherBLUE CROSS BLUE SHIELD