Provider Demographics
NPI:1316553860
Name:WILLOW CREEK PERFECT TEETH PC
Entity Type:Organization
Organization Name:WILLOW CREEK PERFECT TEETH PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:DIANE
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:BRION-MARTIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:720-441-3423
Mailing Address - Street 1:7160 DALLAS PKWY STE 400
Mailing Address - Street 2:
Mailing Address - City:PLANO
Mailing Address - State:TX
Mailing Address - Zip Code:75024-7111
Mailing Address - Country:US
Mailing Address - Phone:720-441-3423
Mailing Address - Fax:
Practice Address - Street 1:8150 S QUEBEC ST STE C
Practice Address - Street 2:
Practice Address - City:CENTENNIAL
Practice Address - State:CO
Practice Address - Zip Code:80112-3186
Practice Address - Country:US
Practice Address - Phone:720-728-6530
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-09-21
Last Update Date:2020-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental