Healthcare Provider Details

I. General information

NPI: 1396079471
Provider Name (Legal Business Name): RICHARD T. CHISHOLM D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/23/2009
Last Update Date: 09/23/2009
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
MONROE UT
84754-0069
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 Number324143
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: