Provider Demographics
NPI:1770615122
Name:KANAWHA COUNTY DENTAL HEALTH COUNCIL INC
Entity type:Organization
Organization Name:KANAWHA COUNTY DENTAL HEALTH COUNCIL INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:LISA
Authorized Official - Middle Name:ANNE
Authorized Official - Last Name:MOORE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:304-348-6613
Mailing Address - Street 1:1900 SCHOOL ST
Mailing Address - Street 2:KANAWHA DENTAL HEALTH COUNCIL INC
Mailing Address - City:CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25312
Mailing Address - Country:US
Mailing Address - Phone:304-348-6613
Mailing Address - Fax:
Practice Address - Street 1:1900 SCHOOL ST
Practice Address - Street 2:KDHC
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25312
Practice Address - Country:US
Practice Address - Phone:304-348-6613
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-12
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0012835000Medicaid