Basic Information
| Provider Information | |||||||||
| NPI: | 1962800680 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CHERRY STREET SERVICES INC | ||||||||
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| OtherOrganizationName: | BARRY COMMUNTIY HEALTH CENTER - DENTAL | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 100 CHERRY ST SE | ||||||||
| Address2: | |||||||||
| City: | GRAND RAPIDS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 495034526 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6169658200 | ||||||||
| FaxNumber: | 6169405366 | ||||||||
| Practice Location | |||||||||
| Address1: | 1230 W STATE ST | ||||||||
| Address2: | |||||||||
| City: | HASTINGS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 490589712 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2699454220 | ||||||||
| FaxNumber: | 2699454229 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/11/2014 | ||||||||
| LastUpdateDate: | 12/15/2014 | ||||||||
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| AuthorizedOfficialLastName: | SHEA | ||||||||
| AuthorizedOfficialFirstName: | CHRIS | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 6167762129 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223D0001X | Y | 193400000X SINGLE SPECIALTY GROUP | Dental Providers | Dentist | Dental Public Health |
ID Information
| ID | Type | State | Issuer | Description | H80CS00770 | 01 | MI | HRSA | OTHER |