Healthcare Provider Details

I. General information

NPI: 1316553860
Provider Name (Legal Business Name): WILLOW CREEK PERFECT TEETH PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/21/2020
Last Update Date: 09/21/2020
Certification Date: 09/21/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8150 S QUEBEC ST STE C
CENTENNIAL CO
80112-3186
US

IV. Provider business mailing address

7160 DALLAS PKWY STE 400
PLANO TX
75024-7111
US

V. Phone/Fax

Practice location:
  • Phone: 720-728-6530
  • Fax:
Mailing address:
  • Phone: 720-441-3423
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DIANE MARIE BRION-MARTIN
Title or Position: CREDENTIALING MANAGER
Credential:
Phone: 720-441-3423