Healthcare Provider Details

I. General information

NPI: 1558768770
Provider Name (Legal Business Name): CREEKSIDE DENTISTRY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/03/2014
Last Update Date: 12/03/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3238 KRISAM CREEK DR
LOGANVILLE GA
30052-7942
US

IV. Provider business mailing address

3238 KRISAM CREEK DR
LOGANVILLE GA
30052-7942
US

V. Phone/Fax

Practice location:
  • Phone: 770-466-0474
  • Fax: 770-466-3894
Mailing address:
  • Phone: 770-466-0474
  • Fax: 770-466-3894

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberGA8776
License Number StateGA

VIII. Authorized Official

Name: CYNDI SIMMONS
Title or Position: PRACTICE MANAGER
Credential:
Phone: 770-466-0474