Provider Demographics
NPI:1083028948
Name:COUNTY OF CLEVELAND NORTH CAROLINA
Entity Type:Organization
Organization Name:COUNTY OF CLEVELAND NORTH CAROLINA
Other - Org Name:CLEVELAND COUNTY DENTAL CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:HEALTH DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:DOROTHEA
Authorized Official - Middle Name:
Authorized Official - Last Name:WYANT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:704-484-5100
Mailing Address - Street 1:315 E GROVER ST
Mailing Address - Street 2:
Mailing Address - City:SHELBY
Mailing Address - State:NC
Mailing Address - Zip Code:28150-3919
Mailing Address - Country:US
Mailing Address - Phone:704-484-5100
Mailing Address - Fax:704-484-5220
Practice Address - Street 1:315 E GROVER ST
Practice Address - Street 2:
Practice Address - City:SHELBY
Practice Address - State:NC
Practice Address - Zip Code:28150-3919
Practice Address - Country:US
Practice Address - Phone:704-484-5100
Practice Address - Fax:704-484-5220
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:COUNTY OF CLEVELAND NORTH CAROLINA
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-06-18
Last Update Date:2014-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP0905XAmbulatory Health Care FacilitiesClinic/CenterPublic Health, State or Local
No261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC2344813Medicaid