Healthcare Provider Details

I. General information

NPI: 1568501229
Provider Name (Legal Business Name): DR. R. BRUCE COCHRANE DDS, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/06/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

318 S MAPLE ST
CARROLL IA
51401-3100
US

IV. Provider business mailing address

1611 1ST AVE N
FORT DODGE IA
50501-4253
US

V. Phone/Fax

Practice location:
  • Phone: 712-792-6313
  • Fax: 712-792-6314
Mailing address:
  • Phone: 515-576-8151
  • Fax: 515-576-5670

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number6251
License Number StateIA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier2143495
Identifier TypeMEDICAID
Identifier StateIA
Identifier Issuer

VIII. Authorized Official

Name: JEAN M HOOVER
Title or Position: OFFICE MANAGER
Credential: RDA
Phone: 515-576-8151