Provider Demographics
NPI:1457506586
Name:COMFORT DENTAL NORTH PUEBLO
Entity Type:Organization
Organization Name:COMFORT DENTAL NORTH PUEBLO
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:PHILIP
Authorized Official - Middle Name:BREDEE
Authorized Official - Last Name:HOLDEN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:719-542-2472
Mailing Address - Street 1:2025 US HIGHWAY 50 WEST
Mailing Address - Street 2:SUITE A100
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81008
Mailing Address - Country:US
Mailing Address - Phone:719-542-2472
Mailing Address - Fax:719-542-6435
Practice Address - Street 1:2025 US HIGHWAY 50 WEST
Practice Address - Street 2:SUITE A100
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81008
Practice Address - Country:US
Practice Address - Phone:719-542-2472
Practice Address - Fax:719-542-6435
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-11-17
Last Update Date:2008-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO7394261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO92728375Medicaid