=====================================================
General NPI Number Information
=====================================================
NPI Number | 1629779137
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | GRACE COEN
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/13/2023
-----------------------------------------------------
Last Update Date | 11/26/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2900 DOOLITTLE DR
-----------------------------------------------------
City | ELLSWORTH AFB
-----------------------------------------------------
State | SD
-----------------------------------------------------
Zip | 57706-4821
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 605-385-3657
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 804 PARK AVE APT 304
-----------------------------------------------------
City | OMAHA
-----------------------------------------------------
State | NE
-----------------------------------------------------
Zip | 68105-2170
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 641-831-0257
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | D11795
-----------------------------------------------------
License Number State | OR
-----------------------------------------------------