MEDICARE: COMFORT DENTAL OF NORTH VALLEY

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry

General Provider Information

NPI Number	:	1932409778
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	COMFORT DENTAL OF NORTH VALLEY

Provider Business Mailing Address
First Line	:	5308 4TH ST NW
Second Line	:
City	:	ALBUQUERQUE
State	:	NM
Zip	:	87107-5206
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	5308 4TH ST NW
Second Line	:
City	:	ALBUQUERQUE
State	:	NM
Zip	:	87107-5206
Country	:	US
Telephone Number	:	505-341-2273
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	DOUGLAS CHISHOLM
Credential	:
Telephone Number	:	505-341-2273

Provider Enumeration Date	:	10/27/2010
Last Update Date	:	10/27/2010

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Directions to “COMFORT DENTAL OF NORTH VALLEY ” Practice Location

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