Provider Demographics
NPI:1457618670
Name:CREEKSIDE DENTAL P.C.
Entity Type:Organization
Organization Name:CREEKSIDE DENTAL P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:KENT
Authorized Official - Middle Name:T
Authorized Official - Last Name:MELBOURNE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS, MBA
Authorized Official - Phone:865-688-7695
Mailing Address - Street 1:2606 GREENWAY DR
Mailing Address - Street 2:SUITE 201
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37918-1904
Mailing Address - Country:US
Mailing Address - Phone:865-688-7699
Mailing Address - Fax:865-688-7695
Practice Address - Street 1:2606 GREENWAY DR
Practice Address - Street 2:SUITE 201
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37918-1904
Practice Address - Country:US
Practice Address - Phone:865-688-7699
Practice Address - Fax:865-688-7695
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-04-12
Last Update Date:2012-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty