Provider Demographics
NPI:1639584717
Name:PROSPECT CHARTERCARE SJHSRI, LLC
Entity Type:Organization
Organization Name:PROSPECT CHARTERCARE SJHSRI, LLC
Other - Org Name:ST. JOSEPH DENTAL ASSOCIATES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SECRETARY
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:JON
Authorized Official - Last Name:ELDERS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:714-788-1249
Mailing Address - Street 1:200 HIGH SERVICE AVE
Mailing Address - Street 2:
Mailing Address - City:NORTH PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02904-5113
Mailing Address - Country:US
Mailing Address - Phone:401-456-3000
Mailing Address - Fax:401-456-3028
Practice Address - Street 1:21 PEACE ST
Practice Address - Street 2:
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02907-1510
Practice Address - Country:US
Practice Address - Phone:401-456-4321
Practice Address - Fax:401-456-4369
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-06-26
Last Update Date:2021-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty