Provider Demographics
NPI:1568856177
Name:KOFFORD, CREE (DMD,MD)
Entity Type:Individual
Prefix:DR
First Name:CREE
Middle Name:
Last Name:KOFFORD
Suffix:
Gender:M
Credentials:DMD,MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:550 S JACKSON ST
Mailing Address - Street 2:2ND FLOOR ORAL SURGERY CLINIC
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40202-5831
Mailing Address - Country:US
Mailing Address - Phone:502-852-8990
Mailing Address - Fax:502-852-8551
Practice Address - Street 1:550 S JACKSON ST FL 2
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40202-1622
Practice Address - Country:US
Practice Address - Phone:502-852-8990
Practice Address - Fax:502-852-8551
Is Sole Proprietor?:No
Enumeration Date:2015-03-20
Last Update Date:2021-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CODEN.002046431223S0112X
CODR.00657441223S0112X
390200000X
KY96131223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program