Provider Demographics
NPI:1306357447
Name:COUNTRY CREEK DENTAL PLLC
Entity Type:Organization
Organization Name:COUNTRY CREEK DENTAL PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:NATHAN
Authorized Official - Middle Name:
Authorized Official - Last Name:LA MONICA
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:775-291-0075
Mailing Address - Street 1:7605 GILMORE LN
Mailing Address - Street 2:
Mailing Address - City:CORRYTON
Mailing Address - State:TN
Mailing Address - Zip Code:37721-4128
Mailing Address - Country:US
Mailing Address - Phone:775-291-0075
Mailing Address - Fax:
Practice Address - Street 1:207 KINGS CT
Practice Address - Street 2:
Practice Address - City:ALCOA
Practice Address - State:TN
Practice Address - Zip Code:37701-1939
Practice Address - Country:US
Practice Address - Phone:865-983-6361
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-10-16
Last Update Date:2017-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN10031261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental