Provider Demographics
NPI:1902410947
Name:CREEK DENTAL GROUP MEADOWBROOK LLC
Entity Type:Organization
Organization Name:CREEK DENTAL GROUP MEADOWBROOK LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VP
Authorized Official - Prefix:
Authorized Official - First Name:MARCI
Authorized Official - Middle Name:
Authorized Official - Last Name:NICOL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-312-1722
Mailing Address - Street 1:1275 E FORT UNION BLVD STE 100
Mailing Address - Street 2:
Mailing Address - City:MIDVALE
Mailing Address - State:UT
Mailing Address - Zip Code:84047-1890
Mailing Address - Country:US
Mailing Address - Phone:801-918-4135
Mailing Address - Fax:
Practice Address - Street 1:1148 E UT-193
Practice Address - Street 2:
Practice Address - City:LAYTON
Practice Address - State:UT
Practice Address - Zip Code:84040
Practice Address - Country:US
Practice Address - Phone:801-383-0147
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-09-08
Last Update Date:2020-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty