Provider Demographics
NPI:1760860670
Name:COMFORT DENTAL GREEN VALLEY RANCH
Entity Type:Organization
Organization Name:COMFORT DENTAL GREEN VALLEY RANCH
Other - Org Name:COMFORT DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:ANDREW LISTER
Authorized Official - Last Name:SEVERANCE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:719-359-1699
Mailing Address - Street 1:18437 E AMHERST DR
Mailing Address - Street 2:
Mailing Address - City:AURORA
Mailing Address - State:CO
Mailing Address - Zip Code:80013-6151
Mailing Address - Country:US
Mailing Address - Phone:719-359-1699
Mailing Address - Fax:
Practice Address - Street 1:18620 GREEN VALLEY RANCH BLVD STE 103
Practice Address - Street 2:
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80249-6842
Practice Address - Country:US
Practice Address - Phone:303-371-8247
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-05-12
Last Update Date:2015-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO305S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305S00000XManaged Care OrganizationsPoint of Service