Provider Demographics
NPI:1174861793
Name:COMFORTABLE CARE DENTAL HEALTH PROFESSIONALS, P.A.
Entity Type:Organization
Organization Name:COMFORTABLE CARE DENTAL HEALTH PROFESSIONALS, P.A.
Other - Org Name:SOUTH LAKE DENTAL CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:INSURANCE/CREDENTIALING
Authorized Official - Prefix:
Authorized Official - First Name:ALLISON
Authorized Official - Middle Name:
Authorized Official - Last Name:VARNER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:217-540-5100
Mailing Address - Street 1:2233 COUNTY ROAD 210 WEST
Mailing Address - Street 2:
Mailing Address - City:ST. JOHNS
Mailing Address - State:FL
Mailing Address - Zip Code:32259
Mailing Address - Country:US
Mailing Address - Phone:904-494-8115
Mailing Address - Fax:
Practice Address - Street 1:2233 COUNTY ROAD 210 WEST
Practice Address - Street 2:
Practice Address - City:ST. JOHNS
Practice Address - State:FL
Practice Address - Zip Code:32259
Practice Address - Country:US
Practice Address - Phone:904-494-8115
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:COMFORTABLE CARE DENTAL HEALTH PROFESSIONALS P.A.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2013-01-17
Last Update Date:2013-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty