Healthcare Provider Details

I. General information

NPI: 1689762528
Provider Name (Legal Business Name): JOHN STEPHEN COCKERHAM D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/10/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1421 S 28TH AVE
HATTIESBURG MS
39402-3108
US

IV. Provider business mailing address

1421 S 28TH AVE
HATTIESBURG MS
39402-3108
US

V. Phone/Fax

Practice location:
  • Phone: 601-264-7611
  • Fax: 601-268-0693
Mailing address:
  • Phone: 601-264-7611
  • Fax: 601-268-0693

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberOS 20-77
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: