Provider Demographics
NPI:1861463465
Name:CREEKVIEW DENTAL PA
Entity Type:Organization
Organization Name:CREEKVIEW DENTAL PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT S CORP
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:M
Authorized Official - Last Name:HAAG
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:651-738-8204
Mailing Address - Street 1:2145 WOODLANE DR
Mailing Address - Street 2:SUITE 104
Mailing Address - City:WOODBURY
Mailing Address - State:MN
Mailing Address - Zip Code:55125-1920
Mailing Address - Country:US
Mailing Address - Phone:651-738-8204
Mailing Address - Fax:
Practice Address - Street 1:2145 WOODLANE DR
Practice Address - Street 2:SUITE 104
Practice Address - City:WOODBURY
Practice Address - State:MN
Practice Address - Zip Code:55125-1920
Practice Address - Country:US
Practice Address - Phone:651-738-8204
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-31
Last Update Date:2012-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNMN10688122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty