Provider Demographics
NPI:1558768770
Name:CREEKSIDE DENTISTRY, LLC
Entity Type:Organization
Organization Name:CREEKSIDE DENTISTRY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:CYNDI
Authorized Official - Middle Name:
Authorized Official - Last Name:SIMMONS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-466-0474
Mailing Address - Street 1:3238 KRISAM CREEK DR
Mailing Address - Street 2:
Mailing Address - City:LOGANVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30052-7942
Mailing Address - Country:US
Mailing Address - Phone:770-466-0474
Mailing Address - Fax:770-466-3894
Practice Address - Street 1:3238 KRISAM CREEK DR
Practice Address - Street 2:
Practice Address - City:LOGANVILLE
Practice Address - State:GA
Practice Address - Zip Code:30052-7942
Practice Address - Country:US
Practice Address - Phone:770-466-0474
Practice Address - Fax:770-466-3894
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-12-03
Last Update Date:2014-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAGA87761223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty