Provider Demographics
NPI:1972632644
Name:COFFEY, GEORGINA G (DMD)
Entity type:Individual
Prefix:DR
First Name:GEORGINA
Middle Name:G
Last Name:COFFEY
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24 BOZARD ST
Mailing Address - Street 2:P.O. BOX 1291
Mailing Address - City:MANNING
Mailing Address - State:SC
Mailing Address - Zip Code:29102-2935
Mailing Address - Country:US
Mailing Address - Phone:803-435-8845
Mailing Address - Fax:
Practice Address - Street 1:24 BOZARD ST
Practice Address - Street 2:
Practice Address - City:MANNING
Practice Address - State:SC
Practice Address - Zip Code:29102-2935
Practice Address - Country:US
Practice Address - Phone:803-435-8845
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCSC39381223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCZX3938Medicaid