Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223P0106X | Oral and Maxillofacial Pathology | 2165 | SC |
NPI | 1831156777 |
---|---|
Provider Name | Dr. Larry Wayne Cobb |
First Address | Greenville, SC 29607-2414 |
Second Address | Greenville, SC 29607-2414 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 26/04/2006 |
Last Update Date | 08/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
T24224 | (02) | SC |
Z21655 | (05) | SC |