Provider Demographics
NPI:1114169661
Name:COMMONWEALTH HEALTH FREE CLINIC, INC
Entity Type:Organization
Organization Name:COMMONWEALTH HEALTH FREE CLINIC, INC
Other - Org Name:THE DENTAL CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:RONALD
Authorized Official - Middle Name:G
Authorized Official - Last Name:SOWELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:270-781-9765
Mailing Address - Street 1:PO BOX 9577
Mailing Address - Street 2:
Mailing Address - City:BOWLING GREEN
Mailing Address - State:KY
Mailing Address - Zip Code:42102-9577
Mailing Address - Country:US
Mailing Address - Phone:270-745-1467
Mailing Address - Fax:270-745-1156
Practice Address - Street 1:740 E 10TH AVE
Practice Address - Street 2:
Practice Address - City:BOWLING GREEN
Practice Address - State:KY
Practice Address - Zip Code:42101-2318
Practice Address - Country:US
Practice Address - Phone:270-781-9765
Practice Address - Fax:270-782-6461
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-03-30
Last Update Date:2009-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty