Provider Demographics
NPI:1255499083
Name:CHISHOLM FAMILY DENTISTRY INC
Entity Type:Organization
Organization Name:CHISHOLM FAMILY DENTISTRY INC
Other - Org Name:RICHARD T CHILSHOLM DDS
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:DENTIST OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:T
Authorized Official - Last Name:CHILSHOLM
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:435-527-3555
Mailing Address - Street 1:PO BOX 69
Mailing Address - Street 2:30 S MAIN ST
Mailing Address - City:MONROE
Mailing Address - State:UT
Mailing Address - Zip Code:84754
Mailing Address - Country:US
Mailing Address - Phone:435-527-3555
Mailing Address - Fax:435-527-3618
Practice Address - Street 1:30 S MAIN ST
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:UT
Practice Address - Zip Code:84754
Practice Address - Country:US
Practice Address - Phone:435-527-3555
Practice Address - Fax:435-527-3618
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-05
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT32414399211223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT528376111001Medicaid
UT528376111001Medicaid