MEDICARE: DR. TERRELL COHEN D.D.S.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223P0300X	Periodontics	24961	CA

General Provider Information

NPI Number	:	1114921194
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. TERRELL COHEN D.D.S.

Provider Business Mailing Address
First Line	:	375 PLANCHA WAY
Second Line	:
City	:	ARROYO GRANDE
State	:	CA
Zip	:	93420-4610
Country	:	US
Telephone Number	:	805-747-4584
Fax Number	:

Provider Business Practice Location Address
First Line	:	1090 DOLLIVER ST
Second Line	:
City	:	PISMO BEACH
State	:	CA
Zip	:	93449-2508
Country	:	US
Telephone Number	:	805-773-2500
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/08/2005
Last Update Date	:	03/06/2010

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