Basic Information
| Provider Information | |||||||||
| NPI: | 1740630128 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PENINSULA COMMUNITY HEALTH SERVICES | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | PCHS DENTAL 6TH | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 960 | ||||||||
| Address2: | |||||||||
| City: | BREMERTON | ||||||||
| State: | WA | ||||||||
| PostalCode: | 983370212 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3603773776 | ||||||||
| FaxNumber: | 3604790038 | ||||||||
| Practice Location | |||||||||
| Address1: | 616 6TH ST | ||||||||
| Address2: | |||||||||
| City: | BREMERTON | ||||||||
| State: | WA | ||||||||
| PostalCode: | 983371420 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3603773776 | ||||||||
| FaxNumber: | 3604790038 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/16/2016 | ||||||||
| LastUpdateDate: | 04/20/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | KREIDLER-MOSS | ||||||||
| AuthorizedOfficialFirstName: | JENNIFER | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 3603773776 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 04/20/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QF0400X | N | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) | 1223G0001X | Y | 193400000X SINGLE SPECIALTY GROUP | Dental Providers | Dentist | General Practice |
ID Information
| ID | Type | State | Issuer | Description | NPI | 05 | WA | MEDICAID |