=====================================================
General NPI Number Information
=====================================================
NPI Number | 1568501229
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DR. R. BRUCE COCHRANE DDS, PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/06/2007
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 318 S MAPLE ST
-----------------------------------------------------
City | CARROLL
-----------------------------------------------------
State | IA
-----------------------------------------------------
Zip | 51401-3100
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 712-792-6313
-----------------------------------------------------
Fax | 712-792-6314
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1611 1ST AVE N
-----------------------------------------------------
City | FORT DODGE
-----------------------------------------------------
State | IA
-----------------------------------------------------
Zip | 50501-4253
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 515-576-8151
-----------------------------------------------------
Fax | 515-576-5670
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OFFICE MANAGER
-----------------------------------------------------
Name | JEAN M HOOVER
-----------------------------------------------------
Credential | RDA
-----------------------------------------------------
Telephone | 515-576-8151
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223P0300X
-----------------------------------------------------
Taxonomy Name | Periodontics
-----------------------------------------------------
License Number | 6251
-----------------------------------------------------
License Number State | IA
-----------------------------------------------------