Provider Demographics
NPI:1417973025
Name:LAFAYETTE COMFORT DENTAL
Entity Type:Organization
Organization Name:LAFAYETTE COMFORT DENTAL
Other - Org Name:COMFORT DENTAL LAFYETTE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:HANAA
Authorized Official - Middle Name:M
Authorized Official - Last Name:JEBRIL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:303-604-2804
Mailing Address - Street 1:535 W SOUTH BOULDER RD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:LAFAYETTE
Mailing Address - State:CO
Mailing Address - Zip Code:80026-2097
Mailing Address - Country:US
Mailing Address - Phone:303-604-2804
Mailing Address - Fax:303-604-0576
Practice Address - Street 1:535 W SOUTH BOULDER RD
Practice Address - Street 2:SUITE 200
Practice Address - City:LAFAYETTE
Practice Address - State:CO
Practice Address - Zip Code:80026-2097
Practice Address - Country:US
Practice Address - Phone:303-604-2804
Practice Address - Fax:303-604-0576
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-15
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO72491223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO09606564Medicaid