Healthcare Provider Details

I. General information

NPI: 1639331382
Provider Name (Legal Business Name): STEPHEN DUANE COCHRAN DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/25/2008
Last Update Date: 06/25/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8355 BAYBERRY RD
JACKSONVILLE FL
32256-4427
US

IV. Provider business mailing address

8355 BAYBERRY RD
JACKSONVILLE FL
32256-4427
US

V. Phone/Fax

Practice location:
  • Phone: 904-733-7254
  • Fax: 904-731-0144
Mailing address:
  • Phone: 904-733-7254
  • Fax: 904-731-0144

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License NumberDN12667
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: