Provider Demographics
NPI:1548594526
Name:THIRD STREET DENTAL MOBILE VAN
Entity Type:Organization
Organization Name:THIRD STREET DENTAL MOBILE VAN
Other - Org Name:THIRD STREET FAMILY HEALTH SERVICES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:PEGGY
Authorized Official - Middle Name:
Authorized Official - Last Name:ANDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:419-522-6191
Mailing Address - Street 1:600 W 3RD ST
Mailing Address - Street 2:
Mailing Address - City:MANSFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:44906-2633
Mailing Address - Country:US
Mailing Address - Phone:419-522-6191
Mailing Address - Fax:419-526-4911
Practice Address - Street 1:600 W 3RD ST
Practice Address - Street 2:
Practice Address - City:MANSFIELD
Practice Address - State:OH
Practice Address - Zip Code:44906-2633
Practice Address - Country:US
Practice Address - Phone:419-522-6191
Practice Address - Fax:419-526-4911
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:THIRD STREET COMMUNITY CLINIC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-09-24
Last Update Date:2022-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)