Provider Demographics
NPI:1154662369
Name:GASTON FAMILY HEALTH SERVICES, INC.
Entity Type:Organization
Organization Name:GASTON FAMILY HEALTH SERVICES, INC.
Other - Org Name:GASTON FAMILY HEALTH SERVICES DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DENTAL BUSINESS ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:KAREN
Authorized Official - Middle Name:F
Authorized Official - Last Name:EDWARDS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:704-862-6182
Mailing Address - Street 1:991 W HUDSON BLVD
Mailing Address - Street 2:
Mailing Address - City:GASTONIA
Mailing Address - State:NC
Mailing Address - Zip Code:28052-6430
Mailing Address - Country:US
Mailing Address - Phone:704-862-6182
Mailing Address - Fax:704-671-1404
Practice Address - Street 1:991 W HUDSON BLVD
Practice Address - Street 2:
Practice Address - City:GASTONIA
Practice Address - State:NC
Practice Address - Zip Code:28052-6430
Practice Address - Country:US
Practice Address - Phone:704-862-6182
Practice Address - Fax:704-671-1404
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:GASTON FAMILY HEALTH SERVICES, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2013-03-13
Last Update Date:2013-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
No1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC344574DMedicaid