Provider Demographics
NPI:1346320116
Name:COFFMAN, FRED D (DDS)
Entity Type:Individual
Prefix:DR
First Name:FRED
Middle Name:D
Last Name:COFFMAN
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 1:576 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
Is Sole Proprietor?:No
Enumeration Date:2006-10-16
Last Update Date:2008-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA0291421223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice