MEDICARE: EAGLE CREEK DENTISTRY, INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy
1	1223G0001X	General Practice Dentistry
2	1223X0400X	Orthodontics and Dentofacial Orthopedics Dentistry
3	124Q00000X	Dental Hygienist
4	126800000X	Dental Assistant
5	261QD0000X	Dental Clinic/Center
6	122300000X	Dentist

General Provider Information

NPI Number	:	1639391725
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EAGLE CREEK DENTISTRY, INC.

Provider Business Mailing Address
First Line	:	12692 TAMIAMI TRL E
Second Line	:
City	:	NAPLES
State	:	FL
Zip	:	34113-8431
Country	:	US
Telephone Number	:	239-417-6453
Fax Number	:	239-775-6628

Provider Business Practice Location Address
First Line	:	12692 TAMIAMI TRL E
Second Line	:
City	:	NAPLES
State	:	FL
Zip	:	34113-8431
Country	:	US
Telephone Number	:	239-417-6453
Fax Number	:	239-775-6628

Authorized Official
Title or Position	:	OFFICE MANAGER
Name	:	MEAGHAN DANIELLE VALENTINE
Credential	:
Telephone Number	:	239-398-4410

Provider Enumeration Date	:	05/02/2007
Last Update Date	:	04/10/2023

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