Healthcare Provider Details

I. General information

NPI: 1639391725
Provider Name (Legal Business Name): EAGLE CREEK DENTISTRY, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/02/2007
Last Update Date: 04/10/2023
Certification Date: 04/10/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12692 TAMIAMI TRL E
NAPLES FL
34113-8431
US

IV. Provider business mailing address

12692 TAMIAMI TRL E
NAPLES FL
34113-8431
US

V. Phone/Fax

Practice location:
  • Phone: 239-417-6453
  • Fax: 239-775-6628
Mailing address:
  • Phone: 239-417-6453
  • Fax: 239-775-6628

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code126800000X
TaxonomyDental Assistant
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MEAGHAN DANIELLE VALENTINE
Title or Position: OFFICE MANAGER
Credential:
Phone: 239-398-4410