Provider Demographics
NPI:1780819516
Name:WILLOW CREEK DENTAL PC
Entity Type:Organization
Organization Name:WILLOW CREEK DENTAL PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:BRANDON
Authorized Official - Middle Name:D
Authorized Official - Last Name:GORDON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:208-552-0919
Mailing Address - Street 1:PO BOX 50938
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83405-0938
Mailing Address - Country:US
Mailing Address - Phone:208-552-0919
Mailing Address - Fax:208-552-1010
Practice Address - Street 1:1380 LATAH AVE
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83402
Practice Address - Country:US
Practice Address - Phone:208-552-0919
Practice Address - Fax:208-552-1010
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-05-22
Last Update Date:2009-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD-4179261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental