Provider Demographics
NPI:1952635930
Name:COMFORTABLE CARE DENTAL HEALTH PROFESSIONALS, P.A.
Entity Type:Organization
Organization Name:COMFORTABLE CARE DENTAL HEALTH PROFESSIONALS, P.A.
Other - Org Name:BANYAN DENTAL CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING TEAM LEAD
Authorized Official - Prefix:
Authorized Official - First Name:CASSANDRA
Authorized Official - Middle Name:
Authorized Official - Last Name:PETERSEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:217-540-8972
Mailing Address - Street 1:1250 TAMIAMI TRL N
Mailing Address - Street 2:S107
Mailing Address - City:NAPLES
Mailing Address - State:FL
Mailing Address - Zip Code:34102-5248
Mailing Address - Country:US
Mailing Address - Phone:239-263-4445
Mailing Address - Fax:239-263-1558
Practice Address - Street 1:1250 TAMIAMI TRL N
Practice Address - Street 2:S107
Practice Address - City:NAPLES
Practice Address - State:FL
Practice Address - Zip Code:34102-5248
Practice Address - Country:US
Practice Address - Phone:239-263-4445
Practice Address - Fax:239-263-1558
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:COMFORTABLE CARE DENTAL HEALTH PROFE
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-09-24
Last Update Date:2023-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL8320/FL94551223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty