Provider Demographics
NPI:1013367036
Name:CITY CREEK DENTAL, PLLC
Entity Type:Organization
Organization Name:CITY CREEK DENTAL, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:WALTER
Authorized Official - Middle Name:LANDON
Authorized Official - Last Name:BYE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:801-364-7943
Mailing Address - Street 1:175 S WEST TEMPLE STE 100
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84101-1443
Mailing Address - Country:US
Mailing Address - Phone:801-364-7943
Mailing Address - Fax:801-364-3373
Practice Address - Street 1:175 S WEST TEMPLE STE 100
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84101-1443
Practice Address - Country:US
Practice Address - Phone:801-364-7943
Practice Address - Fax:801-364-3373
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-06-21
Last Update Date:2016-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT5673900261QD0000X
UT7991108261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental