Healthcare Provider Details

I. General information

NPI: 1609285089
Provider Name (Legal Business Name): COMFORTABLE CARE DENTAL HEALTH PROFESSIONALS, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/11/2014
Last Update Date: 08/11/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

149 TUSCAN WAY
ST. AUGUSTINE FL
32092-1860
US

IV. Provider business mailing address

149 TUSCAN WAY
ST. AUGUSTINE FL
32092-1860
US

V. Phone/Fax

Practice location:
  • Phone: 904-201-3205
  • Fax:
Mailing address:
  • Phone: 904-201-3205
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDN19379
License Number StateFL

VIII. Authorized Official

Name: ALLISON VARNER
Title or Position: CREDENTIALING COORDINATOR
Credential:
Phone: 217-540-6077