Provider Demographics
NPI:1689762528
Name:COCKERHAM, JOHN STEPHEN (DDS)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:STEPHEN
Last Name:COCKERHAM
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1421 S 28TH AVE
Mailing Address - Street 2:
Mailing Address - City:HATTIESBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39402-3108
Mailing Address - Country:US
Mailing Address - Phone:601-264-7611
Mailing Address - Fax:601-268-0693
Practice Address - Street 1:1421 S 28TH AVE
Practice Address - Street 2:
Practice Address - City:HATTIESBURG
Practice Address - State:MS
Practice Address - Zip Code:39402-3108
Practice Address - Country:US
Practice Address - Phone:601-264-7611
Practice Address - Fax:601-268-0693
Is Sole Proprietor?:No
Enumeration Date:2006-10-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSOS 20-771223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS1602-74OtherDENTAL LICENSE
MS0660132Medicaid
MS0660132Medicaid