Provider Demographics
NPI:1588781314
Name:COMFORTABLE CARE DENTAL HEALTH PROFESSIONALS, P.A.
Entity type:Organization
Organization Name:COMFORTABLE CARE DENTAL HEALTH PROFESSIONALS, P.A.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING SUPERVISOR
Authorized Official - Prefix:MS
Authorized Official - First Name:HEATHER
Authorized Official - Middle Name:
Authorized Official - Last Name:PRUEMER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:217-540-8434
Mailing Address - Street 1:1831 NE 45TH ST
Mailing Address - Street 2:SUITE B
Mailing Address - City:FORT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33308-5117
Mailing Address - Country:US
Mailing Address - Phone:954-771-3331
Mailing Address - Fax:954-771-7795
Practice Address - Street 1:1831 NE 45TH ST
Practice Address - Street 2:SUITE B
Practice Address - City:FORT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33308-5117
Practice Address - Country:US
Practice Address - Phone:954-771-3331
Practice Address - Fax:954-771-7795
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:COMFORTABLE CARE DENTAL HEALTH PROFESSIONALS, P.A.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-03-25
Last Update Date:2017-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN00112991223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty