Provider Demographics
NPI:1407933500
Name:COFFMAN, JEFFREY DAVID (DDS)
Entity Type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:DAVID
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 1:14 N SPRING ST
Mailing Address - Street 2:
Mailing Address - City:BUCKHANNON
Mailing Address - State:WV
Mailing Address - Zip Code:26201-2720
Mailing Address - Country:US
Mailing Address - Phone:304-472-1122
Mailing Address - Fax:304-472-1939
Practice Address - Street 1:14 N SPRING ST
Practice Address - Street 2:
Practice Address - City:BUCKHANNON
Practice Address - State:WV
Practice Address - Zip Code:26201-2720
Practice Address - Country:US
Practice Address - Phone:304-472-1122
Practice Address - Fax:304-472-1939
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-01
Last Update Date:2016-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV35821223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3810000801Medicaid
WV3582OtherSTATE TAX ID