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General NPI Number Information
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NPI Number | 1134514086
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Entity Type | Organization
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Legal Business Name | COMFORTABLE CARE DENTAL HEALTH PROFESSIONALS, PA
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Dates
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Enumeration Date | 03/30/2015
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Last Update Date | 04/24/2015
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Provider Practice Location Address
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Address Line | 1384 SW ST. LUCIE
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City | PORT ST. LUCIE
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State | FL
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Zip | 34986
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Country | US
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Telephone | 772-380-4469
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Fax |
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Provider Business Mailing Address
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Address Line | 1384 SW ST. LUCIE WEST
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City | PORT ST. LUCIE
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State | FL
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Zip | 34986
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | CREDENTIALING COORDINATOR
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Name | KENDRA WALKER
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Credential |
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Telephone | 217-540-8312
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | DN20755
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License Number State | FL
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