Healthcare Provider Details

I. General information

NPI: 1295561983
Provider Name (Legal Business Name): CREEKSIDE DENTAL, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/10/2024
Last Update Date: 09/10/2024
Certification Date: 09/10/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4904 TIMBER RIDGE DR STE 203
DOUGLASVILLE GA
30135-1831
US

IV. Provider business mailing address

4904 TIMBER RIDGE DR STE 203
DOUGLASVILLE GA
30135-1831
US

V. Phone/Fax

Practice location:
  • Phone: 770-577-5727
  • Fax: 770-577-7542
Mailing address:
  • Phone: 770-577-5727
  • Fax: 770-577-7542

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: PAMELA DEAS
Title or Position: OFFICE MANAGER
Credential:
Phone: 770-577-5727