Healthcare Provider Details

I. General information

NPI: 1770001612
Provider Name (Legal Business Name): CREEK CAPITAL ORCHARD DRIVE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/30/2017
Last Update Date: 08/30/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3377 ORCHARD DR
BOUNTIFUL UT
84010-8005
US

IV. Provider business mailing address

678 E VINE ST STE 10
MURRAY UT
84107-5500
US

V. Phone/Fax

Practice location:
  • Phone: 801-951-8038
  • Fax:
Mailing address:
  • Phone: 801-918-4135
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: MARCI NICOL
Title or Position: COO
Credential:
Phone: 801-312-7122