Provider Demographics
NPI:1336200054
Name:COGHLAN, ELAINE (DDS)
Entity Type:Individual
Prefix:DR
First Name:ELAINE
Middle Name:
Last Name:COGHLAN
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 1:312 S SWAIN AVENUE
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47401-3723
Mailing Address - Country:US
Mailing Address - Phone:812-332-1866
Mailing Address - Fax:812-332-5540
Practice Address - Street 1:312 S SWAIN AVENUE
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47401-3723
Practice Address - Country:US
Practice Address - Phone:812-332-1866
Practice Address - Fax:812-332-5540
Is Sole Proprietor?:No
Enumeration Date:2006-12-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12008909122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist