Healthcare Provider Details

I. General information

NPI: 1083329866
Provider Name (Legal Business Name): COMFORTABLE CARE DENTAL HEALTH PROFESSIONALS, P.A.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/17/2023
Last Update Date: 01/17/2023
Certification Date: 01/17/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

136A STAFF DR NE
FT WALTON BCH FL
32548-5062
US

IV. Provider business mailing address

136A STAFF DR NE
FT WALTON BCH FL
32548-5062
US

V. Phone/Fax

Practice location:
  • Phone: 850-243-3566
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State

VIII. Authorized Official

Name: HILLARY THULL
Title or Position: CREDENTIALING COORDINATOR
Credential:
Phone: 217-540-8946