Healthcare Provider Details

I. General information

NPI: 1982918983
Provider Name (Legal Business Name): COLBY J COCKRELL DMD PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/02/2010
Last Update Date: 08/02/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

504 UNION AVE SE
OLYMPIA WA
98501-1429
US

IV. Provider business mailing address

PO BOX 2525
OLYMPIA WA
98507-2525
US

V. Phone/Fax

Practice location:
  • Phone: 360-943-6331
  • Fax: 360-943-2293
Mailing address:
  • Phone: 360-943-6331
  • Fax: 360-943-2293

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License NumberDE60023798
License Number StateWA

VIII. Authorized Official

Name: DR. COLBY J COCKRELL
Title or Position: OWNER
Credential: DMD
Phone: 360-943-6331