Provider Demographics
NPI:1659408276
Name:CREEKSIDE FAMILY DENTAL PC
Entity Type:Organization
Organization Name:CREEKSIDE FAMILY DENTAL PC
Other - Org Name:BRYAN K NAKAGAWA DMD
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:BRYAN
Authorized Official - Middle Name:
Authorized Official - Last Name:NAKAGAWA
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:503-581-2454
Mailing Address - Street 1:620 12TH ST SE
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97301-4001
Mailing Address - Country:US
Mailing Address - Phone:503-581-2454
Mailing Address - Fax:503-581-1819
Practice Address - Street 1:620 12TH ST SE
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97301-4001
Practice Address - Country:US
Practice Address - Phone:503-581-2454
Practice Address - Fax:503-581-1819
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-28
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR79341223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty