Provider Demographics
NPI:1407374341
Name:CREEK CAPITAL STANSBURY PARK LLC
Entity Type:Organization
Organization Name:CREEK CAPITAL STANSBURY PARK LLC
Other - Org Name:BURG CHILDREN'S DENTISTRY & ORTHODONTICS-STANSBURY PARK
Other - Org Type:Doing Business As
Authorized Official - Title/Position:COO
Authorized Official - Prefix:
Authorized Official - First Name:MARCI
Authorized Official - Middle Name:
Authorized Official - Last Name:NICOL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-312-7122
Mailing Address - Street 1:678 E VINE ST
Mailing Address - Street 2:
Mailing Address - City:MURRAY
Mailing Address - State:UT
Mailing Address - Zip Code:84107-5546
Mailing Address - Country:US
Mailing Address - Phone:801-312-7122
Mailing Address - Fax:
Practice Address - Street 1:220 MILLPOND STE 107
Practice Address - Street 2:
Practice Address - City:STANSBURY PARK
Practice Address - State:UT
Practice Address - Zip Code:84074-9760
Practice Address - Country:US
Practice Address - Phone:435-843-5437
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-08-30
Last Update Date:2017-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty