=====================================================
General NPI Number Information
=====================================================
NPI Number | 1730740259
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CHERY DENTAL LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/25/2019
-----------------------------------------------------
Last Update Date | 06/04/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 200 S ORANGE AVE
-----------------------------------------------------
City | GREEN COVE SPRINGS
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32043-4130
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-297-8416
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 200 S ORANGE AVE
-----------------------------------------------------
City | GREEN COVE SPRINGS
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32043-4130
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-297-8416
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DENTIST
-----------------------------------------------------
Name | DR. NADERGE DELPHONSE CHERY
-----------------------------------------------------
Credential | DMD
-----------------------------------------------------
Telephone | 904-297-8416
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------