Provider Demographics
NPI:1003174970
Name:COMFORTABLE CARE DENTAL HEALTH PROFESSIONALS
Entity Type:Organization
Organization Name:COMFORTABLE CARE DENTAL HEALTH PROFESSIONALS
Other - Org Name:DENTAL DESIGNS AT LAKESIDE VILLAGE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING/INSURANCE
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 1:7828 WINTER GARDEN VINELAND RD STE 100
Mailing Address - Street 2:
Mailing Address - City:WINDERMERE
Mailing Address - State:FL
Mailing Address - Zip Code:34786-5933
Mailing Address - Country:US
Mailing Address - Phone:321-244-4118
Mailing Address - Fax:
Practice Address - Street 1:7828 WINTER GARDEN VINELAND RD STE 100
Practice Address - Street 2:
Practice Address - City:WINDERMERE
Practice Address - State:FL
Practice Address - Zip Code:34786-5933
Practice Address - Country:US
Practice Address - Phone:321-244-4118
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:COMFORTABLE CARE DENTAL HEALTH PROFESSIONALS
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-04-30
Last Update Date:2021-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty