Provider Demographics
NPI:1912319583
Name:CREATIVE DENTAL GROUP, PLLC
Entity Type:Organization
Organization Name:CREATIVE DENTAL GROUP, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:MRUGANK
Authorized Official - Middle Name:M
Authorized Official - Last Name:SARDHARA
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:630-456-6334
Mailing Address - Street 1:800 PLEASANT ST
Mailing Address - Street 2:APT 809
Mailing Address - City:NEW BEDFORD
Mailing Address - State:MA
Mailing Address - Zip Code:02740-6100
Mailing Address - Country:US
Mailing Address - Phone:630-456-6334
Mailing Address - Fax:
Practice Address - Street 1:160 RODNEY FRENCH BLVD
Practice Address - Street 2:
Practice Address - City:NEW BEDFORD
Practice Address - State:MA
Practice Address - Zip Code:02744-1640
Practice Address - Country:US
Practice Address - Phone:630-456-6334
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-05-29
Last Update Date:2014-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MADN1856486122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty