MEDICARE: COMFORTABLE CARE DENTAL HEALTH PROFESSIONALS, PA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry

General Provider Information

NPI Number	:	1205164183
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	COMFORTABLE CARE DENTAL HEALTH PROFESSIONALS, PA

Provider Business Mailing Address
First Line	:	13720 OLD SAINT AUGUSTINE RD STE 5
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32258-7415
Country	:	US
Telephone Number	:	904-292-1002
Fax Number	:	904-292-1004

Provider Business Practice Location Address
First Line	:	13720 OLD SAINT AUGUSTINE RD STE 5
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32258-7415
Country	:	US
Telephone Number	:	904-292-1002
Fax Number	:	904-292-1004

Authorized Official
Title or Position	:	INSURANCE/CREDENTIALING
Name	:	PAM HARDIEK
Credential	:
Telephone Number	:	217-540-5100

Provider Enumeration Date	:	12/03/2009
Last Update Date	:	12/03/2009

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