Provider Demographics
NPI:1386193068
Name:RICHLAND CREEK DENTAL LLC
Entity Type:Organization
Organization Name:RICHLAND CREEK DENTAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:MCKENZIE
Authorized Official - Middle Name:
Authorized Official - Last Name:BOLING
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:423-834-9900
Mailing Address - Street 1:668 DAYCO DR
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:TN
Mailing Address - Zip Code:37321-6733
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1272 MARKET ST
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:TN
Practice Address - Zip Code:37321
Practice Address - Country:US
Practice Address - Phone:423-834-9900
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-09-23
Last Update Date:2016-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN10259122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty