Provider Demographics
NPI:1326281163
Name:CARE CREEK DENTAL LLC
Entity Type:Organization
Organization Name:CARE CREEK DENTAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:A
Authorized Official - Last Name:GAGNON
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:208-233-8620
Mailing Address - Street 1:1169 CALL CREEK DR STE A
Mailing Address - Street 2:
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83201-3077
Mailing Address - Country:US
Mailing Address - Phone:208-233-8620
Mailing Address - Fax:
Practice Address - Street 1:1169 CALL CREEK DR STE A
Practice Address - Street 2:
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83201-3077
Practice Address - Country:US
Practice Address - Phone:208-233-8620
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-04-09
Last Update Date:2009-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD-39461223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty