Provider Demographics
NPI:1336449636
Name:CHERRYHILLS DENTAL
Entity Type:Organization
Organization Name:CHERRYHILLS DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:
Authorized Official - Last Name:TILSON
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:505-821-1433
Mailing Address - Street 1:7007 WYOMING BLVD NE STE A4
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87109-6941
Mailing Address - Country:US
Mailing Address - Phone:505-821-1433
Mailing Address - Fax:505-821-1422
Practice Address - Street 1:7007 WYOMING BLVD NE STE A4
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87109-6941
Practice Address - Country:US
Practice Address - Phone:505-821-1433
Practice Address - Fax:505-821-1422
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-11-02
Last Update Date:2010-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMDD16111223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty