Provider Demographics
NPI:1689103038
Name:POWELL, CREIGHTON DESHAWN (DDS)
Entity type:Individual
Prefix:
First Name:CREIGHTON
Middle Name:DESHAWN
Last Name:POWELL
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:205 RIVER PLACE DR UNIT 511
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30909-0062
Mailing Address - Country:US
Mailing Address - Phone:501-940-5502
Mailing Address - Fax:
Practice Address - Street 1:143 TRAFALGAR ST SW
Practice Address - Street 2:
Practice Address - City:AIKEN
Practice Address - State:SC
Practice Address - Zip Code:29801-3760
Practice Address - Country:US
Practice Address - Phone:803-641-1000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-08
Last Update Date:2025-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC103351223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR168292631Medicaid
SCZX0335Medicaid