Provider Demographics
NPI:1114317294
Name:COMFORTABLE CARE DENTAL HEALTH PROFESSIONALS, P.A.
Entity Type:Organization
Organization Name:COMFORTABLE CARE DENTAL HEALTH PROFESSIONALS, P.A.
Other - Org Name:BROOKER CREEK DENTAL GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CRED SUPERIVOSR
Authorized Official - Prefix:
Authorized Official - First Name:KIM
Authorized Official - Middle Name:
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:217-540-5170
Mailing Address - Street 1:36207 E LAKE RD
Mailing Address - Street 2:
Mailing Address - City:PALM HARBOR
Mailing Address - State:FL
Mailing Address - Zip Code:34685-3143
Mailing Address - Country:US
Mailing Address - Phone:727-787-9696
Mailing Address - Fax:727-786-2334
Practice Address - Street 1:36207 E LAKE RD
Practice Address - Street 2:
Practice Address - City:PALM HARBOR
Practice Address - State:FL
Practice Address - Zip Code:34685-3143
Practice Address - Country:US
Practice Address - Phone:727-787-9696
Practice Address - Fax:727-786-2334
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:COMFORTABLE CARE DENTAL HEALTH PROFESSIONALS, P.A.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-01-28
Last Update Date:2015-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty