Basic Information
| Provider Information | |||||||||
| NPI: | 1871844167 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | COMMUNITY HEALTH SERVICE AGENCY,INC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | CHSA DENTAL CLINIC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4500 WESLEY ST | ||||||||
| Address2: | |||||||||
| City: | GREENVILLE | ||||||||
| State: | TX | ||||||||
| PostalCode: | 754015644 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9034543025 | ||||||||
| FaxNumber: | 9034501408 | ||||||||
| Practice Location | |||||||||
| Address1: | 3600 CADDO ST | ||||||||
| Address2: | |||||||||
| City: | GREENVILLE | ||||||||
| State: | TX | ||||||||
| PostalCode: | 754014511 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9034546965 | ||||||||
| FaxNumber: | 9034547981 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/26/2012 | ||||||||
| LastUpdateDate: | 04/23/2015 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | CARTER | ||||||||
| AuthorizedOfficialFirstName: | MICHELLE | ||||||||
| AuthorizedOfficialMiddleName: | P | ||||||||
| AuthorizedOfficialTitleorPosition: | CHEIF EXECUTIVE OFFICIER | ||||||||
| AuthorizedOfficialTelephone: | 9034555986 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | CEO | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223S0112X | N | 193400000X SINGLE SPECIALTY GROUP | Dental Providers | Dentist | Oral and Maxillofacial Surgery | 261QF0400X | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
No ID Information.