Healthcare Provider Details

I. General information

NPI: 1720452436
Provider Name (Legal Business Name): COMFORTABLE CARE DENTAL HEALTH PROFESSIONALS, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/18/2015
Last Update Date: 11/18/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2301 OLD CANOE CREEK RD
ST. CLOUD FL
34772
US

IV. Provider business mailing address

2301 OLD CANOE CREEK RD
ST. CLOUD FL
34772
US

V. Phone/Fax

Practice location:
  • Phone: 321-926-4159
  • 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: KENDRA WALKER
Title or Position: CREDENTIALING TEAM LEAD
Credential:
Phone: 217-540-8312