Provider Demographics
NPI:1467619064
Name:COMFORT DENTAL CENTRE GALLOWAY
Entity Type:Organization
Organization Name:COMFORT DENTAL CENTRE GALLOWAY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:THELRUTH
Authorized Official - Middle Name:
Authorized Official - Last Name:SHAW
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:214-398-1234
Mailing Address - Street 1:2929 N GALLOWAY AVE STE 116
Mailing Address - Street 2:
Mailing Address - City:MESQUITE
Mailing Address - State:TX
Mailing Address - Zip Code:75150-4800
Mailing Address - Country:US
Mailing Address - Phone:972-681-2500
Mailing Address - Fax:972-681-2501
Practice Address - Street 1:2929 N GALLOWAY AVE STE 116
Practice Address - Street 2:
Practice Address - City:MESQUITE
Practice Address - State:TX
Practice Address - Zip Code:75150-4800
Practice Address - Country:US
Practice Address - Phone:972-681-2500
Practice Address - Fax:972-681-2501
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-21
Last Update Date:2008-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX13654122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX090281902Medicaid