Provider Demographics
NPI:1104859495
Name:COTHREN, TOBY GREGORY (DDS)
Entity type:Individual
Prefix:DR
First Name:TOBY
Middle Name:GREGORY
Last Name:COTHREN
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4500 CLEVELAND PL
Mailing Address - Street 2:
Mailing Address - City:METAIRIE
Mailing Address - State:LA
Mailing Address - Zip Code:70003-1246
Mailing Address - Country:US
Mailing Address - Phone:504-454-3687
Mailing Address - Fax:
Practice Address - Street 1:812 PARK AVE
Practice Address - Street 2:
Practice Address - City:MANDEVILLE
Practice Address - State:LA
Practice Address - Zip Code:70448-4921
Practice Address - Country:US
Practice Address - Phone:985-624-7400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA32651223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1832651Medicaid