=====================================================
General NPI Number Information
=====================================================
NPI Number | 1821248964
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | COMFORT DENTAL
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/25/2008
-----------------------------------------------------
Last Update Date | 09/25/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1482 BROAD ST
-----------------------------------------------------
City | PROVIDENCE
-----------------------------------------------------
State | RI
-----------------------------------------------------
Zip | 02905-2836
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 401-781-5151
-----------------------------------------------------
Fax | 401-781-5252
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1482 BROAD ST
-----------------------------------------------------
City | PROVIDENCE
-----------------------------------------------------
State | RI
-----------------------------------------------------
Zip | 02905-2836
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 401-781-5151
-----------------------------------------------------
Fax | 401-781-5252
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | BUSINESS MEMBER
-----------------------------------------------------
Name | MS. LIZBETH RIVERA
-----------------------------------------------------
Credential | BM
-----------------------------------------------------
Telephone | 401-781-5151
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 2560
-----------------------------------------------------
License Number State | RI
-----------------------------------------------------