Basic Information
| Provider Information | |||||||||
| NPI: | 1093206450 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CREEK CAPITOL ORTHODONTICS- HUNTER PARK | ||||||||
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| OtherOrganizationName: | BURG ORTHODONTICS HUNTER PARK | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 678 E VINE ST STE 10 | ||||||||
| Address2: | |||||||||
| City: | MURRAY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 841075500 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8019184135 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2792 S 5600 W | ||||||||
| Address2: | |||||||||
| City: | WEST VALLEY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 841205590 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8019699669 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/22/2018 | ||||||||
| LastUpdateDate: | 05/22/2018 | ||||||||
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| AuthorizedOfficialLastName: | NICOL | ||||||||
| AuthorizedOfficialFirstName: | MARCI | ||||||||
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| AuthorizedOfficialTitleorPosition: | COO | ||||||||
| AuthorizedOfficialTelephone: | 8019184135 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223X0400X | Y | 193400000X SINGLE SPECIALTY GROUP | Dental Providers | Dentist | Orthodontics and Dentofacial Orthopedics |
No ID Information.