Provider Demographics
NPI:1912058058
Name:WEST SIDE COMMUNITY HEALTH SERVICES, INC.
Entity Type:Organization
Organization Name:WEST SIDE COMMUNITY HEALTH SERVICES, INC.
Other - Org Name:EAST SIDE FAMILY DENTAL CLINIC
Other - Org Type:Other Name
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:REUBEN
Authorized Official - Middle Name:
Authorized Official - Last Name:MOORE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:651-602-7500
Mailing Address - Street 1:153 CESAR CHAVEZ ST
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55107-2226
Mailing Address - Country:US
Mailing Address - Phone:651-602-7500
Mailing Address - Fax:651-602-7513
Practice Address - Street 1:895 E. 7TH ST
Practice Address - Street 2:
Practice Address - City:ST PAUL
Practice Address - State:MN
Practice Address - Zip Code:55106-3852
Practice Address - Country:US
Practice Address - Phone:651-772-9757
Practice Address - Fax:651-772-9959
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WEST SIDE COMMUNITY HEALTH SERVICES, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-01-16
Last Update Date:2024-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN302133261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN955353300Medicaid
MN241856Medicare Oscar/Certification
MNC00143Medicare PIN