Provider Demographics
NPI:1881730729
Name:COFFEY, JOHN WALTER (DDS)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:WALTER
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 1:806 S PINE STREET
Mailing Address - Street 2:
Mailing Address - City:STILLWATER
Mailing Address - State:OK
Mailing Address - Zip Code:74074
Mailing Address - Country:US
Mailing Address - Phone:405-377-1155
Mailing Address - Fax:405-377-1914
Practice Address - Street 1:806 S PINE STREET
Practice Address - Street 2:
Practice Address - City:STILLWATER
Practice Address - State:OK
Practice Address - Zip Code:74074
Practice Address - Country:US
Practice Address - Phone:405-377-1155
Practice Address - Fax:405-377-1155
Is Sole Proprietor?:No
Enumeration Date:2007-01-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKD3048122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist