Provider Demographics
NPI:1912049636
Name:RICHARD I. COCKE JR., P.S.C.
Entity Type:Organization
Organization Name:RICHARD I. COCKE JR., P.S.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:IVANHOE
Authorized Official - Last Name:COCKE
Authorized Official - Suffix:III
Authorized Official - Credentials:DMD
Authorized Official - Phone:270-395-4349
Mailing Address - Street 1:41 INDUSTRIAL PWY
Mailing Address - Street 2:P.O. BOX 625
Mailing Address - City:CALVERT CITY
Mailing Address - State:KY
Mailing Address - Zip Code:42029
Mailing Address - Country:US
Mailing Address - Phone:270-395-4349
Mailing Address - Fax:270-395-0175
Practice Address - Street 1:41 INDUSTRIAL PWY
Practice Address - Street 2:
Practice Address - City:CALVERT CITY
Practice Address - State:KY
Practice Address - Zip Code:42029
Practice Address - Country:US
Practice Address - Phone:270-395-4349
Practice Address - Fax:270-395-0175
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-12
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY5127122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY60051273Medicaid