Healthcare Provider Details

I. General information

NPI: 1376353540
Provider Name (Legal Business Name): BREANNA KAITLYN COCHRAN RDH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/09/2025
Last Update Date: 01/09/2025
Certification Date: 01/09/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9625 PROMINENT PT STE 100
COLORADO SPRINGS CO
80924-5005
US

IV. Provider business mailing address

3513 SAGUARO CIR
COLORADO SPRINGS CO
80925-1179
US

V. Phone/Fax

Practice location:
  • Phone: 719-495-5748
  • Fax:
Mailing address:
  • Phone: 910-797-8180
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License NumberDH.002027165
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: