Healthcare Provider Details

I. General information

NPI: 1114647013
Provider Name (Legal Business Name): CEDRIC DEAN CPP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: CEDRIC DEAN CPP

II. Dates (important events)

Enumeration Date: 08/31/2022
Last Update Date: 06/24/2024
Certification Date: 06/24/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2001 CATHERINE SIMMONS AVE
CHARLOTTE NC
28216-4677
US

IV. Provider business mailing address

5502 MCCHESNEY DR
CHARLOTTE NC
28269-7188
US

V. Phone/Fax

Practice location:
  • Phone: 704-492-1533
  • Fax:
Mailing address:
  • Phone: 704-492-5509
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171WH0202X
TaxonomyHome Modifications Contractor
License Number2021877201
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code251K00000X
TaxonomyPublic Health or Welfare Agency
License Number2021877201
License Number StateNC
# 3
Primary TaxonomyN
Taxonomy Code305R00000X
TaxonomyPreferred Provider Organization
License Number2021877201
License Number StateNC
# 4
Primary TaxonomyY
Taxonomy Code405300000X
TaxonomyPrevention Professional
License Number2021877201
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: