Provider Demographics
NPI:1871769901
Name:FRED D COFFMAN DDS INC
Entity type:Organization
Organization Name:FRED D COFFMAN DDS INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:FRED
Authorized Official - Middle Name:D
Authorized Official - Last Name:COFFMAN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:916-784-3337
Mailing Address - Street 1:576 N SUNRISE AVE STE 130
Mailing Address - Street 2:
Mailing Address - City:ROSEVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95661-2846
Mailing Address - Country:US
Mailing Address - Phone:916-784-3337
Mailing Address - Fax:916-784-7459
Practice Address - Street 1:576 N SUNRISE AVE STE 130
Practice Address - Street 2:
Practice Address - City:ROSEVILLE
Practice Address - State:CA
Practice Address - Zip Code:95661-2846
Practice Address - Country:US
Practice Address - Phone:916-784-3337
Practice Address - Fax:916-784-7459
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-08
Last Update Date:2008-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA029142261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental