Provider Demographics
NPI:1952574261
Name:KERRY P. COGBURN, DDS, PA
Entity Type:Organization
Organization Name:KERRY P. COGBURN, DDS, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:KERRY
Authorized Official - Middle Name:P
Authorized Official - Last Name:COGBURN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS,PA
Authorized Official - Phone:828-627-9285
Mailing Address - Street 1:418 JONES COVE RD
Mailing Address - Street 2:
Mailing Address - City:CLYDE
Mailing Address - State:NC
Mailing Address - Zip Code:28721-9458
Mailing Address - Country:US
Mailing Address - Phone:828-627-9285
Mailing Address - Fax:828-627-9287
Practice Address - Street 1:418 JONES COVE RD
Practice Address - Street 2:
Practice Address - City:CLYDE
Practice Address - State:NC
Practice Address - Zip Code:28721-9458
Practice Address - Country:US
Practice Address - Phone:828-627-9285
Practice Address - Fax:828-627-9287
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-08
Last Update Date:2008-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC39061223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8991701Medicaid