Provider Demographics
NPI:1972007912
Name:COMFORTABLE CARE DENTAL HEALTH PROFESSIONALS, P.A.
Entity Type:Organization
Organization Name:COMFORTABLE CARE DENTAL HEALTH PROFESSIONALS, P.A.
Other - Org Name:NORTH PORT ORAL SURGERY & DENTISTRY
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 1:2787 SYCAMORE ST STE 106
Mailing Address - Street 2:
Mailing Address - City:NORTH PORT
Mailing Address - State:FL
Mailing Address - Zip Code:34289-9513
Mailing Address - Country:US
Mailing Address - Phone:941-423-1750
Mailing Address - Fax:
Practice Address - Street 1:2787 SYCAMORE ST STE 106
Practice Address - Street 2:
Practice Address - City:NORTH PORT
Practice Address - State:FL
Practice Address - Zip Code:34289-9513
Practice Address - Country:US
Practice Address - Phone:941-423-1750
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:COMFORTABLE CARE DENTAL HEALTH PROFESSIONALS, P.A.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2018-03-23
Last Update Date:2018-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty