Provider Demographics
NPI:1669793790
Name:COMFORTABLE CARE DENTAL HEALTH PROFESSIONALS
Entity type:Organization
Organization Name:COMFORTABLE CARE DENTAL HEALTH PROFESSIONALS
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:INSURANCE / CREDENTIALING
Authorized Official - Prefix:
Authorized Official - First Name:PAM
Authorized Official - Middle Name:
Authorized Official - Last Name:HARDIEK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:217-540-5100
Mailing Address - Street 1:1345 W GRANADA BLVD UNIT 9
Mailing Address - Street 2:
Mailing Address - City:ORMOND BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32174-8191
Mailing Address - Country:US
Mailing Address - Phone:386-672-8175
Mailing Address - Fax:386-672-8179
Practice Address - Street 1:1345 W GRANADA BLVD UNIT 9
Practice Address - Street 2:
Practice Address - City:ORMOND BEACH
Practice Address - State:FL
Practice Address - Zip Code:32174-8191
Practice Address - Country:US
Practice Address - Phone:386-672-8175
Practice Address - Fax:386-672-8179
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:COMFORTABLE CARE DENTAL HEALTH PROFESSIONALS
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-06-11
Last Update Date:2010-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty