Provider Demographics
NPI:1710303300
Name:COGBURN, ROBERT (DMD)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:
Last Name:COGBURN
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 1:1950 DOUGLAS BLVD
Mailing Address - Street 2:STE B1
Mailing Address - City:ROSEVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95661-3825
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1950 DOUGLAS BLVD
Practice Address - Street 2:STE B1
Practice Address - City:ROSEVILLE
Practice Address - State:CA
Practice Address - Zip Code:95661-3825
Practice Address - Country:US
Practice Address - Phone:916-783-7105
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-03-06
Last Update Date:2014-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA62973122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist