=====================================================
General NPI Number Information
=====================================================
NPI Number | 1790907475
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | WM TREVOR COFFEE DDS PA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/03/2007
-----------------------------------------------------
Last Update Date | 07/14/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 901 S ELM ST
-----------------------------------------------------
City | HOPE
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 71801-6518
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 870-777-2577
-----------------------------------------------------
Fax | 870-777-2587
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 901 S ELM ST
-----------------------------------------------------
City | HOPE
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 71801-6518
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 870-777-2577
-----------------------------------------------------
Fax | 870-777-2587
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | WILLIAM TREVOR COFFEE
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 870-777-2577
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 3432
-----------------------------------------------------
License Number State | AR
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 3432
-----------------------------------------------------
License Number State | AR
-----------------------------------------------------