Provider Demographics
NPI:1568028587
Name:COFFMAN DENTAL, LLC
Entity Type:Organization
Organization Name:COFFMAN DENTAL, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JUSTIN
Authorized Official - Middle Name:WILLIAM
Authorized Official - Last Name:COFFMAN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:907-376-5315
Mailing Address - Street 1:351 W SWANSON AVE STE 1
Mailing Address - Street 2:
Mailing Address - City:WASILLA
Mailing Address - State:AK
Mailing Address - Zip Code:99654-6853
Mailing Address - Country:US
Mailing Address - Phone:907-376-5315
Mailing Address - Fax:907-376-7855
Practice Address - Street 1:351 W SWANSON AVE STE 1
Practice Address - Street 2:
Practice Address - City:WASILLA
Practice Address - State:AK
Practice Address - Zip Code:99654-6853
Practice Address - Country:US
Practice Address - Phone:907-376-5315
Practice Address - Fax:907-376-7855
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-05-15
Last Update Date:2019-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty