Provider Demographics
NPI:1093206450
Name:CREEK CAPITOL ORTHODONTICS- HUNTER PARK
Entity Type:Organization
Organization Name:CREEK CAPITOL ORTHODONTICS- HUNTER PARK
Other - Org Name:BURG ORTHODONTICS HUNTER PARK
Other - Org Type:Doing Business As
Authorized Official - Title/Position:COO
Authorized Official - Prefix:
Authorized Official - First Name:MARCI
Authorized Official - Middle Name:
Authorized Official - Last Name:NICOL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-918-4135
Mailing Address - Street 1:678 E VINE ST STE 10
Mailing Address - Street 2:
Mailing Address - City:MURRAY
Mailing Address - State:UT
Mailing Address - Zip Code:84107-5500
Mailing Address - Country:US
Mailing Address - Phone:801-918-4135
Mailing Address - Fax:
Practice Address - Street 1:2792 S 5600 W
Practice Address - Street 2:
Practice Address - City:WEST VALLEY
Practice Address - State:UT
Practice Address - Zip Code:84120-5590
Practice Address - Country:US
Practice Address - Phone:801-969-9669
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-05-22
Last Update Date:2018-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty