Provider Demographics
NPI:1275741126
Name:CRYSTAL CREEK DENTAL
Entity Type:Organization
Organization Name:CRYSTAL CREEK DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:TUAN
Authorized Official - Middle Name:
Authorized Official - Last Name:NGUYEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:972-377-8866
Mailing Address - Street 1:4637 HEDGCOXE RD
Mailing Address - Street 2:SUITE 112
Mailing Address - City:PLANO
Mailing Address - State:TX
Mailing Address - Zip Code:75024-3962
Mailing Address - Country:US
Mailing Address - Phone:972-377-8866
Mailing Address - Fax:972-377-8870
Practice Address - Street 1:4637 HEDGCOXE RD
Practice Address - Street 2:SUITE 112
Practice Address - City:PLANO
Practice Address - State:TX
Practice Address - Zip Code:75024-3962
Practice Address - Country:US
Practice Address - Phone:972-377-8866
Practice Address - Fax:972-377-8870
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-21
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX217361223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty