Provider Demographics
NPI:1417353830
Name:BLUE CREEK ENDODONTICS
Entity Type:Organization
Organization Name:BLUE CREEK ENDODONTICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:ANTHONY
Authorized Official - Last Name:EATON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:901-267-2294
Mailing Address - Street 1:3240 E LOUISE DR
Mailing Address - Street 2:SUITE 110
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-5107
Mailing Address - Country:US
Mailing Address - Phone:208-578-4700
Mailing Address - Fax:
Practice Address - Street 1:3240 E LOUISE DR
Practice Address - Street 2:SUITE 110
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642-5107
Practice Address - Country:US
Practice Address - Phone:208-578-4700
Practice Address - Fax:208-578-4704
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-11-12
Last Update Date:2014-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD-4611-EN1223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223E0200XDental ProvidersDentistEndodonticsGroup - Single Specialty