Provider Demographics
NPI:1538566567
Name:COFFELT, MARIE (DDS)
Entity type:Individual
Prefix:
First Name:MARIE
Middle Name:
Last Name:COFFELT
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 1:1350 SPRING ST NW
Mailing Address - Street 2:STE 600
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30309-2864
Mailing Address - Country:US
Mailing Address - Phone:404-389-1950
Mailing Address - Fax:
Practice Address - Street 1:6225 BRANDON AVE
Practice Address - Street 2:STE 170
Practice Address - City:SPRINGFIELD
Practice Address - State:VA
Practice Address - Zip Code:22150-2526
Practice Address - Country:US
Practice Address - Phone:703-451-3900
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-11-19
Last Update Date:2014-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA04010075491223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA0401007549OtherDENTAL LICENSE