Provider Demographics
NPI:1386828614
Name:CHERRYVILLE DENTAL CLINIC
Entity Type:Organization
Organization Name:CHERRYVILLE DENTAL CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:HUNTER
Authorized Official - Last Name:CLONINGER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:704-435-6916
Mailing Address - Street 1:1015 E CHURCH ST
Mailing Address - Street 2:
Mailing Address - City:CHERRYVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28021-2916
Mailing Address - Country:US
Mailing Address - Phone:704-435-6916
Mailing Address - Fax:704-435-6811
Practice Address - Street 1:106 N MOUNTAIN ST
Practice Address - Street 2:
Practice Address - City:CHERRYVILLE
Practice Address - State:NC
Practice Address - Zip Code:28021-2941
Practice Address - Country:US
Practice Address - Phone:704-435-6916
Practice Address - Fax:704-435-6811
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-21
Last Update Date:2013-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC7118122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC899013AMedicaid