Basic Information
| Provider Information | |||||||||
| NPI: | 1982780300 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CHEROKEE INDIAN HOSPITAL AUTHORITY | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | CIHA DENTAL SURGERY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1 HOSPITAL RD | ||||||||
| Address2: | ROOM 2527 | ||||||||
| City: | CHEROKEE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 287199253 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8284979163 | ||||||||
| FaxNumber: | 8284971723 | ||||||||
| Practice Location | |||||||||
| Address1: | 1 HOSPITAL RD | ||||||||
| Address2: | ROOM 2527 | ||||||||
| City: | CHEROKEE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 287199253 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8284979163 | ||||||||
| FaxNumber: | 8284971723 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/27/2006 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | DANDO | ||||||||
| AuthorizedOfficialFirstName: | JONATHAN | ||||||||
| AuthorizedOfficialMiddleName: | CERI | ||||||||
| AuthorizedOfficialTitleorPosition: | BUSINESS OFFICE MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 8284979163 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | CHEROKEE INDIAN HOSPITAL AUTHORITY | ||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X | 5900092 | NC | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Dental Providers | Dentist | 122300000X | 7905 | NC | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Dental Providers | Dentist | 122300000X | 7736 | NC | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Dental Providers | Dentist | 1223S0112X | 5904310 | NC | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Dental Providers | Dentist | Oral and Maxillofacial Surgery | 1223S0112X | 7873 | NC | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Dental Providers | Dentist | Oral and Maxillofacial Surgery | 1223S0112X | NC | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Dental Providers | Dentist | Oral and Maxillofacial Surgery | 261QD0000X | 8125 | NC | N | Ambulatory Health Care Facilities | Clinic/Center | Dental | 122300000X | NC | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Dental Providers | Dentist |
ID Information
| ID | Type | State | Issuer | Description | 1982780300 | 05 | NC | MEDICAID | 016W5 | 01 | NC | BCBSNC | OTHER |