Healthcare Provider Details

I. General information

NPI: 1255499083
Provider Name (Legal Business Name): CHISHOLM FAMILY DENTISTRY INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/05/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30 S MAIN ST
MONROE UT
84754
US

IV. Provider business mailing address

PO BOX 69 30 S MAIN ST
MONROE UT
84754
US

V. Phone/Fax

Practice location:
  • Phone: 435-527-3555
  • Fax: 435-527-3618
Mailing address:
  • Phone: 435-527-3555
  • Fax: 435-527-3618

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number3241439921
License Number StateUT

VIII. Authorized Official

Name: DR. RICHARD T CHILSHOLM
Title or Position: DENTIST OWNER
Credential: DDS
Phone: 435-527-3555