Provider Demographics
NPI:1942926332
Name:HISTER-COCKRELL, MAIARA LISIANE
Entity Type:Individual
Prefix:
First Name:MAIARA
Middle Name:LISIANE
Last Name:HISTER-COCKRELL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3483 COPPER ACRES
Mailing Address - Street 2:
Mailing Address - City:BULVERDE
Mailing Address - State:TX
Mailing Address - Zip Code:78163
Mailing Address - Country:US
Mailing Address - Phone:210-772-6884
Mailing Address - Fax:
Practice Address - Street 1:3483 COPPER ACRES
Practice Address - Street 2:
Practice Address - City:BULVERDE
Practice Address - State:TX
Practice Address - Zip Code:78163
Practice Address - Country:US
Practice Address - Phone:210-772-6884
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-10-17
Last Update Date:2022-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX39102122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist