Provider Demographics
NPI:1023597119
Name:EPHRATA COMMUNITY DENTAL CLINIC
Entity type:Organization
Organization Name:EPHRATA COMMUNITY DENTAL CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:SHEILA
Authorized Official - Middle Name:
Authorized Official - Last Name:CHILSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:509-766-8971
Mailing Address - Street 1:605 COOLIDGE DRIVE
Mailing Address - Street 2:
Mailing Address - City:MOSES LAKE
Mailing Address - State:WA
Mailing Address - Zip Code:98837
Mailing Address - Country:US
Mailing Address - Phone:509-754-6199
Mailing Address - Fax:
Practice Address - Street 1:204 12TH AVE SW
Practice Address - Street 2:
Practice Address - City:EPHRATA
Practice Address - State:WA
Practice Address - Zip Code:98823-2197
Practice Address - Country:US
Practice Address - Phone:509-754-6199
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MOSES LAKE COMMUNITY HEALTH CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2018-08-09
Last Update Date:2018-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPHHC.FX.60660507261QF0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)