Healthcare Provider Details

I. General information

NPI: 1205012986
Provider Name (Legal Business Name): STACEY ANN COBB HAP 200
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/13/2008
Last Update Date: 03/11/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20108 DOROTHY ST
CANYON COUNTRY CA
91351-3804
US

IV. Provider business mailing address

20108 DOROTHY ST
CANYON COUNTRY CA
91351-3804
US

V. Phone/Fax

Practice location:
  • Phone: 661-299-6602
  • Fax:
Mailing address:
  • Phone: 661-299-6602
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License NumberHAP 200
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: