Provider Demographics
NPI:1689682882
Name:COFFEY, ROGER KENT (DDS)
Entity Type:Individual
Prefix:DR
First Name:ROGER
Middle Name:KENT
Last Name:COFFEY
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10159 IDA OAKS RD
Mailing Address - Street 2:
Mailing Address - City:PELICAN RAPIDS
Mailing Address - State:MN
Mailing Address - Zip Code:56572-9317
Mailing Address - Country:US
Mailing Address - Phone:218-532-2171
Mailing Address - Fax:218-532-2171
Practice Address - Street 1:1790 32ND AVE S
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58103-5942
Practice Address - Country:US
Practice Address - Phone:701-232-0774
Practice Address - Fax:701-232-1158
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-03
Last Update Date:2015-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND17931223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice