Provider Demographics
NPI:1417001280
Name:COFFEY, MICHAEL MATTHEW (LD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:MATTHEW
Last Name:COFFEY
Suffix:
Gender:M
Credentials:LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:616 E FRONT ST
Mailing Address - Street 2:
Mailing Address - City:PORT ANGELES
Mailing Address - State:WA
Mailing Address - Zip Code:98362-3320
Mailing Address - Country:US
Mailing Address - Phone:360-457-6131
Mailing Address - Fax:360-457-6215
Practice Address - Street 1:616 E FRONT ST
Practice Address - Street 2:
Practice Address - City:PORT ANGELES
Practice Address - State:WA
Practice Address - Zip Code:98362-3320
Practice Address - Country:US
Practice Address - Phone:360-457-6131
Practice Address - Fax:360-457-6215
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADN00000399122400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122400000XDental ProvidersDenturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA5048269Medicaid