Provider Demographics
NPI:1790418754
Name:CLEAR CREEK FAMILY DENTAL
Entity Type:Organization
Organization Name:CLEAR CREEK FAMILY DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:BRIANNA
Authorized Official - Middle Name:ROSE
Authorized Official - Last Name:NICHOLS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:417-350-6045
Mailing Address - Street 1:101 S STATE HIGHWAY 125 STE A
Mailing Address - Street 2:
Mailing Address - City:STRAFFORD
Mailing Address - State:MO
Mailing Address - Zip Code:65757-8998
Mailing Address - Country:US
Mailing Address - Phone:417-631-4490
Mailing Address - Fax:417-736-9250
Practice Address - Street 1:101 S STATE HIGHWAY 125 STE A
Practice Address - Street 2:
Practice Address - City:STRAFFORD
Practice Address - State:MO
Practice Address - Zip Code:65757-8998
Practice Address - Country:US
Practice Address - Phone:417-631-4490
Practice Address - Fax:417-736-9250
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CLEAR CREEK FAMILY DENTAL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2022-07-07
Last Update Date:2022-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty