Provider Demographics
NPI:1396299863
Name:COFFEY, JACOB EDWARD (DMD)
Entity type:Individual
Prefix:DR
First Name:JACOB
Middle Name:EDWARD
Last Name:COFFEY
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:690 DONALD DR
Mailing Address - Street 2:
Mailing Address - City:ROLLA
Mailing Address - State:MO
Mailing Address - Zip Code:65401-4803
Mailing Address - Country:US
Mailing Address - Phone:217-827-8033
Mailing Address - Fax:
Practice Address - Street 1:1491 E 10TH ST
Practice Address - Street 2:
Practice Address - City:ROLLA
Practice Address - State:MO
Practice Address - Zip Code:65401-3996
Practice Address - Country:US
Practice Address - Phone:573-364-2868
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-12
Last Update Date:2016-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2016029131122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist