Provider Demographics
NPI:1942840640
Name:CREATIVE DENTAL CLINIC
Entity Type:Organization
Organization Name:CREATIVE DENTAL CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:KONREDDY
Authorized Official - Middle Name:JAINDER
Authorized Official - Last Name:REDDY
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:610-212-6588
Mailing Address - Street 1:2109 DEEP MEADOW LN
Mailing Address - Street 2:
Mailing Address - City:LANSDALE
Mailing Address - State:PA
Mailing Address - Zip Code:19446-7403
Mailing Address - Country:US
Mailing Address - Phone:610-212-6588
Mailing Address - Fax:
Practice Address - Street 1:1537 DEKALB PIKE
Practice Address - Street 2:
Practice Address - City:BLUE BELL
Practice Address - State:PA
Practice Address - Zip Code:19422-3315
Practice Address - Country:US
Practice Address - Phone:484-231-1554
Practice Address - Fax:484-231-1821
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-01-09
Last Update Date:2020-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty