Basic Information
| Provider Information | |||||||||
| NPI: | 1902410947 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CREEK DENTAL GROUP MEADOWBROOK LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1275 E FORT UNION BLVD STE 100 | ||||||||
| Address2: | |||||||||
| City: | MIDVALE | ||||||||
| State: | UT | ||||||||
| PostalCode: | 840471890 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8019184135 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1148 E UT-193 | ||||||||
| Address2: | |||||||||
| City: | LAYTON | ||||||||
| State: | UT | ||||||||
| PostalCode: | 84040 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8013830147 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/08/2020 | ||||||||
| LastUpdateDate: | 09/08/2020 | ||||||||
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| AuthorizedOfficialLastName: | NICOL | ||||||||
| AuthorizedOfficialFirstName: | MARCI | ||||||||
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| AuthorizedOfficialTitleorPosition: | VP | ||||||||
| AuthorizedOfficialTelephone: | 8013121722 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 09/02/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X | Y | 193400000X SINGLE SPECIALTY GROUP | Dental Providers | Dentist |
No ID Information.