Healthcare Provider Details

I. General information

NPI: 1871769901
Provider Name (Legal Business Name): FRED D COFFMAN DDS INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/08/2008
Last Update Date: 05/08/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

576 N SUNRISE AVE STE 130
ROSEVILLE CA
95661-2846
US

IV. Provider business mailing address

576 N SUNRISE AVE STE 130
ROSEVILLE CA
95661-2846
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 Code261QD0000X
TaxonomyDental Clinic/Center
License Number029142
License Number StateCA

VIII. Authorized Official

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