Provider Demographics
NPI:1275702599
Name:CHESHIRE MEDICAL CENTER
Entity Type:Organization
Organization Name:CHESHIRE MEDICAL CENTER
Other - Org Name:CHESHIRE SMILES
Other - Org Type:Other Name
Authorized Official - Title/Position:COMMUNITY HEALTH PROGRAM MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:JOELLYN
Authorized Official - Middle Name:
Authorized Official - Last Name:STACK
Authorized Official - Suffix:
Authorized Official - Credentials:RD, LD, MPH
Authorized Official - Phone:603-354-5400
Mailing Address - Street 1:580 COURT ST
Mailing Address - Street 2:
Mailing Address - City:KEENE
Mailing Address - State:NH
Mailing Address - Zip Code:03431-1718
Mailing Address - Country:US
Mailing Address - Phone:603-354-5494
Mailing Address - Fax:
Practice Address - Street 1:580 COURT ST
Practice Address - Street 2:
Practice Address - City:KEENE
Practice Address - State:NH
Practice Address - Zip Code:03431-1718
Practice Address - Country:US
Practice Address - Phone:603-354-5494
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-21
Last Update Date:2008-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes124Q00000XDental ProvidersDental HygienistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH30532724Medicaid