Provider Demographics
NPI:1447577739
Name:COFFMAN, TAMERA PAGE (DDS)
Entity Type:Individual
Prefix:
First Name:TAMERA
Middle Name:PAGE
Last Name:COFFMAN
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8220 LOUISIANA BLVD NE
Mailing Address - Street 2:SUITE A
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87113-2105
Mailing Address - Country:US
Mailing Address - Phone:505-433-3366
Mailing Address - Fax:505-369-1828
Practice Address - Street 1:8220 LOUISIANA BLVD NE
Practice Address - Street 2:SUITE A
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87113-2105
Practice Address - Country:US
Practice Address - Phone:505-433-3366
Practice Address - Fax:505-369-1828
Is Sole Proprietor?:No
Enumeration Date:2010-04-26
Last Update Date:2012-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMDD32791223G0001X
NMDD32761223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM90574371Medicaid