Provider Demographics
NPI:1396825766
Name:FRED D. COFFMAN, D.D.S., INC.
Entity Type:Organization
Organization Name:FRED D. COFFMAN, D.D.S., INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
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 1:1801 DOUGLAS BLVD
Mailing Address - Street 2:SUITE B
Mailing Address - City:ROSEVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95661-2913
Mailing Address - Country:US
Mailing Address - Phone:916-784-3337
Mailing Address - Fax:916-784-7459
Practice Address - Street 1:1801 DOUGLAS BLVD
Practice Address - Street 2:SUITE B
Practice Address - City:ROSEVILLE
Practice Address - State:CA
Practice Address - Zip Code:95661-2913
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:2006-10-17
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA0291421223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty