Provider Demographics
NPI:1295561983
Name:CREEKSIDE DENTAL, INC.
Entity type:Organization
Organization Name:CREEKSIDE DENTAL, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:PAMELA
Authorized Official - Middle Name:
Authorized Official - Last Name:DEAS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-577-5727
Mailing Address - Street 1:4904 TIMBER RIDGE DR STE 203
Mailing Address - Street 2:
Mailing Address - City:DOUGLASVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30135-1831
Mailing Address - Country:US
Mailing Address - Phone:770-577-5727
Mailing Address - Fax:770-577-7542
Practice Address - Street 1:4904 TIMBER RIDGE DR STE 203
Practice Address - Street 2:
Practice Address - City:DOUGLASVILLE
Practice Address - State:GA
Practice Address - Zip Code:30135-1831
Practice Address - Country:US
Practice Address - Phone:770-577-5727
Practice Address - Fax:770-577-7542
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-09-10
Last Update Date:2024-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental