Provider Demographics
NPI:1225470909
Name:CENTRAL FOSSA LLC
Entity Type:Organization
Organization Name:CENTRAL FOSSA LLC
Other - Org Name:CREEK ROAD DENTAL CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:AMY
Authorized Official - Middle Name:E
Authorized Official - Last Name:FLORANCE DETHORN
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:801-566-5577
Mailing Address - Street 1:7369 CREEK ROAD
Mailing Address - Street 2:
Mailing Address - City:SANDY
Mailing Address - State:UT
Mailing Address - Zip Code:84121
Mailing Address - Country:US
Mailing Address - Phone:801-566-5577
Mailing Address - Fax:801-566-4848
Practice Address - Street 1:7369 CREEK ROAD
Practice Address - Street 2:
Practice Address - City:SANDY
Practice Address - State:UT
Practice Address - Zip Code:84121
Practice Address - Country:US
Practice Address - Phone:801-566-5577
Practice Address - Fax:801-566-4848
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-07-23
Last Update Date:2013-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT8628346122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty