Provider Demographics
NPI:1053477380
Name:COMFORT DENTAL SPA
Entity Type:Organization
Organization Name:COMFORT DENTAL SPA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:DIANA
Authorized Official - Middle Name:
Authorized Official - Last Name:WALKER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:718-699-9500
Mailing Address - Street 1:5121 108TH ST
Mailing Address - Street 2:
Mailing Address - City:CORONA
Mailing Address - State:NY
Mailing Address - Zip Code:11368-3304
Mailing Address - Country:US
Mailing Address - Phone:718-699-9500
Mailing Address - Fax:
Practice Address - Street 1:5121 108TH ST
Practice Address - Street 2:
Practice Address - City:CORONA
Practice Address - State:NY
Practice Address - Zip Code:11368-3304
Practice Address - Country:US
Practice Address - Phone:718-699-9500
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-29
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY=========OtherTAX IDENTIFICATION NUMBER