Provider Demographics
NPI:1710938733
Name:COMSTOCK, J BRETT (DDS)
Entity Type:Individual
Prefix:
First Name:J
Middle Name:BRETT
Last Name:COMSTOCK
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:403 S 11TH ST
Mailing Address - Street 2:#320
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83702-6906
Mailing Address - Country:US
Mailing Address - Phone:208-375-0191
Mailing Address - Fax:
Practice Address - Street 1:403 S 11TH ST
Practice Address - Street 2:#320
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83702-6906
Practice Address - Country:US
Practice Address - Phone:208-375-0191
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD19501223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
U14295Medicare UPIN