Provider Demographics
NPI:1114633922
Name:CLEAR CREEK FAMILY DENTAL ROGERSVILLE
Entity Type:Organization
Organization Name:CLEAR CREEK FAMILY DENTAL ROGERSVILLE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST (PROVIDER)
Authorized Official - Prefix:DR
Authorized Official - First Name:SAMUEL
Authorized Official - Middle Name:R
Authorized Official - Last Name:ZIMMER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:417-929-0000
Mailing Address - Street 1:203 JAMESTOWN BLVD UNIT A
Mailing Address - Street 2:
Mailing Address - City:ROGERSVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:65742-6526
Mailing Address - Country:US
Mailing Address - Phone:417-929-0000
Mailing Address - Fax:417-929-0009
Practice Address - Street 1:203 JAMESTOWN BLVD UNIT A
Practice Address - Street 2:
Practice Address - City:ROGERSVILLE
Practice Address - State:MO
Practice Address - Zip Code:65742-6526
Practice Address - Country:US
Practice Address - Phone:417-929-0000
Practice Address - Fax:417-929-0009
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-01-25
Last Update Date:2023-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental