Healthcare Provider Details

I. General information

NPI: 1275938334
Provider Name (Legal Business Name): COMPREHENSIVE DENTAL GROUP, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/30/2014
Last Update Date: 10/30/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5158 PEACH ST
ERIE PA
16509-2489
US

IV. Provider business mailing address

5158 PEACH ST
ERIE PA
16509-2489
US

V. Phone/Fax

Practice location:
  • Phone: 814-868-3647
  • Fax: 814-864-2715
Mailing address:
  • Phone: 814-868-3647
  • Fax: 814-864-2715

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number
License Number State

VIII. Authorized Official

Name: DR. WILLIAM DALE HAMMERLEE
Title or Position: SOLE MEMBER AND MANAGER
Credential: D.M.D.
Phone: 814-868-3647