Provider Demographics
NPI:1396155131
Name:COFFMAN, JUSTIN (DDS)
Entity type:Individual
Prefix:DR
First Name:JUSTIN
Middle Name:
Last Name:COFFMAN
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:351 W SWANSON AVE STE 1
Mailing Address - Street 2:
Mailing Address - City:WASILLA
Mailing Address - State:AK
Mailing Address - Zip Code:99654-6853
Mailing Address - Country:US
Mailing Address - Phone:907-376-5315
Mailing Address - Fax:
Practice Address - Street 1:351 W SWANSON AVE STE 1
Practice Address - Street 2:
Practice Address - City:WASILLA
Practice Address - State:AK
Practice Address - Zip Code:99654-6853
Practice Address - Country:US
Practice Address - Phone:907-376-5315
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-05-01
Last Update Date:2014-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK1571122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist