Provider Demographics
NPI:1154849081
Name:CREEK CAPITAL VINE STREET LLC
Entity Type:Organization
Organization Name:CREEK CAPITAL VINE STREET LLC
Other - Org Name:BURG CHILDREN'S DENTISTRY & ORTHODONTICS- VINE STREET
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:801-312-1722
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:801-312-1722
Mailing Address - Fax:
Practice Address - Street 1:678 E VINE ST STE 12
Practice Address - Street 2:
Practice Address - City:MURRAY
Practice Address - State:UT
Practice Address - Zip Code:84107-5500
Practice Address - Country:US
Practice Address - Phone:801-268-1135
Practice Address - Fax:801-268-1135
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-08-30
Last Update Date:2017-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty