=====================================================
General NPI Number Information
=====================================================
NPI Number | 1538426374
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | COMFORT CARE DENTISTRY MANAGEMENT LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/18/2012
-----------------------------------------------------
Last Update Date | 05/11/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1711 ORBIT WAY STE 2
-----------------------------------------------------
City | MINDEN
-----------------------------------------------------
State | NV
-----------------------------------------------------
Zip | 89423-4114
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 775-434-2909
-----------------------------------------------------
Fax | 775-552-9801
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1711 ORBIT WAY STE 2
-----------------------------------------------------
City | MINDEN
-----------------------------------------------------
State | NV
-----------------------------------------------------
Zip | 89423-4114
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 775-434-2909
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ACCOUNTANT
-----------------------------------------------------
Name | MARCIE SCHURKE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 775-434-2911
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 4426
-----------------------------------------------------
License Number State | NV
-----------------------------------------------------