Provider Demographics
NPI:1770593519
Name:COMFORT DENTAL THOMPSON VALLEY
Entity type:Organization
Organization Name:COMFORT DENTAL THOMPSON VALLEY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER/DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:FILLMORE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:970-962-9995
Mailing Address - Street 1:1405 10TH ST SW
Mailing Address - Street 2:
Mailing Address - City:LOVELAND
Mailing Address - State:CO
Mailing Address - Zip Code:80537-2301
Mailing Address - Country:US
Mailing Address - Phone:970-962-9995
Mailing Address - Fax:970-461-0693
Practice Address - Street 1:1405 10TH ST SW
Practice Address - Street 2:
Practice Address - City:LOVELAND
Practice Address - State:CO
Practice Address - Zip Code:80537-2301
Practice Address - Country:US
Practice Address - Phone:970-962-9995
Practice Address - Fax:970-461-0693
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-08
Last Update Date:2011-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO9088122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO62382047Medicaid