Healthcare Provider Details

I. General information

NPI: 1396825766
Provider Name (Legal Business Name): FRED D. COFFMAN, D.D.S., INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/17/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1801 DOUGLAS BLVD SUITE B
ROSEVILLE CA
95661-2913
US

IV. Provider business mailing address

1801 DOUGLAS BLVD SUITE B
ROSEVILLE CA
95661-2913
US

V. Phone/Fax

Practice location:
  • Phone: 916-784-3337
  • Fax: 916-784-7459
Mailing address:
  • Phone: 916-784-3337
  • Fax: 916-784-7459

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number029142
License Number StateCA

VIII. Authorized Official

Name: DR. FRED D COFFMAN
Title or Position: PRESIDENT
Credential: DDS
Phone: 916-784-3337