Provider Demographics
NPI:1679943831
Name:CREEKSIDE ORAL & FACIAL SURGERY INC
Entity Type:Organization
Organization Name:CREEKSIDE ORAL & FACIAL SURGERY INC
Other - Org Name:CREEKSIDE ORAL SURGERY
Other - Org Type:Other Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:MAX
Authorized Official - Last Name:ANDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS MD
Authorized Official - Phone:801-255-2422
Mailing Address - Street 1:7390 S CREEK RD
Mailing Address - Street 2:SUITE 101
Mailing Address - City:SANDY
Mailing Address - State:UT
Mailing Address - Zip Code:84093-6119
Mailing Address - Country:US
Mailing Address - Phone:801-255-2422
Mailing Address - Fax:801-255-3013
Practice Address - Street 1:7390 S CREEK RD
Practice Address - Street 2:SUITE 101
Practice Address - City:SANDY
Practice Address - State:UT
Practice Address - Zip Code:84093-6119
Practice Address - Country:US
Practice Address - Phone:801-255-2422
Practice Address - Fax:801-255-3013
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-09-30
Last Update Date:2016-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT315501-99241223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty