Provider Demographics
NPI:1215414875
Name:GOOSE CREEK DENTAL CLINIC
Entity Type:Organization
Organization Name:GOOSE CREEK DENTAL CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:MONICA
Authorized Official - Middle Name:
Authorized Official - Last Name:BURRIDGE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:307-655-8661
Mailing Address - Street 1:642 VAL VISTA ST STE B
Mailing Address - Street 2:
Mailing Address - City:SHERIDAN
Mailing Address - State:WY
Mailing Address - Zip Code:82801-3660
Mailing Address - Country:US
Mailing Address - Phone:307-655-8661
Mailing Address - Fax:307-655-8662
Practice Address - Street 1:642 VAL VISTA ST STE B
Practice Address - Street 2:
Practice Address - City:SHERIDAN
Practice Address - State:WY
Practice Address - Zip Code:82801-3660
Practice Address - Country:US
Practice Address - Phone:307-655-8661
Practice Address - Fax:307-655-8662
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-07-25
Last Update Date:2018-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center