Provider Demographics
NPI:1104804996
Name:COBB, GLENWOOD BROOKS (DMD)
Entity type:Individual
Prefix:DR
First Name:GLENWOOD
Middle Name:BROOKS
Last Name:COBB
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17372 MAIN ST N
Mailing Address - Street 2:
Mailing Address - City:BLOUNTSTOWN
Mailing Address - State:FL
Mailing Address - Zip Code:32424-1763
Mailing Address - Country:US
Mailing Address - Phone:850-674-4124
Mailing Address - Fax:850-674-3545
Practice Address - Street 1:17372 MAIN ST N
Practice Address - Street 2:
Practice Address - City:BLOUNTSTOWN
Practice Address - State:FL
Practice Address - Zip Code:32424-1763
Practice Address - Country:US
Practice Address - Phone:850-674-4124
Practice Address - Fax:850-674-3545
Is Sole Proprietor?:No
Enumeration Date:2006-01-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL00056521223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice