Provider Demographics
NPI:1063986271
Name:COFFEY, BENJAMIN BRUCE (DDS MS)
Entity type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:BRUCE
Last Name:COFFEY
Suffix:
Gender:M
Credentials:DDS MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:424 N HIGH ST
Mailing Address - Street 2:
Mailing Address - City:MORRISTOWN
Mailing Address - State:TN
Mailing Address - Zip Code:37814-3863
Mailing Address - Country:US
Mailing Address - Phone:423-586-2336
Mailing Address - Fax:423-586-2396
Practice Address - Street 1:424 N HIGH ST
Practice Address - Street 2:
Practice Address - City:MORRISTOWN
Practice Address - State:TN
Practice Address - Zip Code:37814-3863
Practice Address - Country:US
Practice Address - Phone:423-586-2336
Practice Address - Fax:423-586-2396
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-22
Last Update Date:2019-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN23861223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty