=====================================================
General NPI Number Information
=====================================================
NPI Number | 1902251127
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | COMFORT CARE DENTAL INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/25/2016
-----------------------------------------------------
Last Update Date | 04/25/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5151 HAZELTINE AVE
-----------------------------------------------------
City | SHERMAN OAKS
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91423-1116
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 818-788-2023
-----------------------------------------------------
Fax | 818-788-1830
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5151 HAZELTINE AVE
-----------------------------------------------------
City | SHERMAN OAKS
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91423-1116
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 818-788-2023
-----------------------------------------------------
Fax | 818-788-1830
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | ROBERT TINGILAN
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 818-788-2023
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 91980
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------