Provider Demographics
NPI:1790169381
Name:ST. VINCENT CHARITY MEDICAL CENTER
Entity Type:Organization
Organization Name:ST. VINCENT CHARITY MEDICAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTAL RESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DYRON
Authorized Official - Middle Name:MICKEY
Authorized Official - Last Name:HOLT
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:865-250-8398
Mailing Address - Street 1:19425 VAN AKEN BLVD
Mailing Address - Street 2:APT. 401
Mailing Address - City:SHAKER HEIGHTS
Mailing Address - State:OH
Mailing Address - Zip Code:44122-3547
Mailing Address - Country:US
Mailing Address - Phone:216-861-6200
Mailing Address - Fax:
Practice Address - Street 1:2351 E 22ND ST
Practice Address - Street 2:SUITE 342W
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44115-3111
Practice Address - Country:US
Practice Address - Phone:316-861-6200
Practice Address - Fax:216-363-7490
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-07-14
Last Update Date:2015-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QS1000XAmbulatory Health Care FacilitiesClinic/CenterStudent Health