Provider Demographics
NPI:1609285089
Name:COMFORTABLE CARE DENTAL HEALTH PROFESSIONALS, PA
Entity Type:Organization
Organization Name:COMFORTABLE CARE DENTAL HEALTH PROFESSIONALS, PA
Other - Org Name:MILL CREEK DENTAL CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING COORDINATOR
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:217-540-6077
Mailing Address - Street 1:149 TUSCAN WAY
Mailing Address - Street 2:
Mailing Address - City:ST. AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32092-1860
Mailing Address - Country:US
Mailing Address - Phone:904-201-3205
Mailing Address - Fax:
Practice Address - Street 1:149 TUSCAN WAY
Practice Address - Street 2:
Practice Address - City:ST. AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32092-1860
Practice Address - Country:US
Practice Address - Phone:904-201-3205
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:COMFORTABLE CARE DENTAL HEALTH PROFESSIONALS, PA
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-08-11
Last Update Date:2014-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN19379122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty