Provider Demographics
NPI:1790907475
Name:WM TREVOR COFFEE DDS PA
Entity Type:Organization
Organization Name:WM TREVOR COFFEE DDS PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:TREVOR
Authorized Official - Last Name:COFFEE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:870-777-2577
Mailing Address - Street 1:901 S ELM ST
Mailing Address - Street 2:
Mailing Address - City:HOPE
Mailing Address - State:AR
Mailing Address - Zip Code:71801-6518
Mailing Address - Country:US
Mailing Address - Phone:870-777-2577
Mailing Address - Fax:870-777-2587
Practice Address - Street 1:901 S ELM ST
Practice Address - Street 2:
Practice Address - City:HOPE
Practice Address - State:AR
Practice Address - Zip Code:71801-6518
Practice Address - Country:US
Practice Address - Phone:870-777-2577
Practice Address - Fax:870-777-2587
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-03
Last Update Date:2008-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR3432122300000X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
No1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty