Basic Information
| Provider Information | |||||||||
| NPI: | 1710517339 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | THIRD STREET COMMUNITY CLINIC, INC. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | 9TH STREET DENTAL CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 600 W 3RD ST | ||||||||
| Address2: | |||||||||
| City: | MANSFIELD | ||||||||
| State: | OH | ||||||||
| PostalCode: | 449062633 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4195226191 | ||||||||
| FaxNumber: | 4195256723 | ||||||||
| Practice Location | |||||||||
| Address1: | 431 E 9TH ST | ||||||||
| Address2: | |||||||||
| City: | ASHLAND | ||||||||
| State: | OH | ||||||||
| PostalCode: | 448051903 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4192891430 | ||||||||
| FaxNumber: | 4195256723 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/23/2020 | ||||||||
| LastUpdateDate: | 07/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | JEREMY | ||||||||
| AuthorizedOfficialFirstName: | THERESA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CREDENTIALING | ||||||||
| AuthorizedOfficialTelephone: | 4195226191 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 07/22/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | N | 193200000X MULTI-SPECIALTY GROUP | Dental Providers | Dentist | General Practice | 261QF0400X | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
No ID Information.