Provider Demographics
NPI:1710344270
Name:COBURN, KATRINA MAVIS (RDH)
Entity Type:Individual
Prefix:
First Name:KATRINA
Middle Name:MAVIS
Last Name:COBURN
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:505 N JACKSON ST
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MI
Mailing Address - Zip Code:49201-1266
Mailing Address - Country:US
Mailing Address - Phone:517-748-5500
Mailing Address - Fax:
Practice Address - Street 1:505 N JACKSON ST
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MI
Practice Address - Zip Code:49201-1266
Practice Address - Country:US
Practice Address - Phone:517-748-5500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-01-28
Last Update Date:2021-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2902013530124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist