Basic Information
| Provider Information | |||||||||
| NPI: | 1003065723 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | COLLIER HEALTH SERVICES INC | ||||||||
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| OtherOrganizationName: | CHS-UF PEDIATRIC DENTAL CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7007 LELY CULTURAL PKWY | ||||||||
| Address2: | EDISON COLLEGE BUILDING L | ||||||||
| City: | NAPLES | ||||||||
| State: | FL | ||||||||
| PostalCode: | 341138976 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2397753052 | ||||||||
| FaxNumber: | 2397757035 | ||||||||
| Practice Location | |||||||||
| Address1: | 1454 MADISON AVE W | ||||||||
| Address2: | |||||||||
| City: | IMMOKALEE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 341422200 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2396583064 | ||||||||
| FaxNumber: | 2396583175 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/18/2008 | ||||||||
| LastUpdateDate: | 11/10/2021 | ||||||||
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| AuthorizedOfficialLastName: | STEELE | ||||||||
| AuthorizedOfficialFirstName: | SANDRA | ||||||||
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| AuthorizedOfficialTitleorPosition: | CHIEF FINANCIAL OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 2396583003 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 11/10/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QF0400X | N | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) | 126800000X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Dental Providers | Dental Assistant | 124Q00000X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Dental Providers | Dental Hygienist | 1223E0200X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Dental Providers | Dentist | Endodontics | 1223P0300X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Dental Providers | Dentist | Periodontics | 1223P0221X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Dental Providers | Dentist | Pediatric Dentistry |
No ID Information.