Healthcare Provider Details

I. General information

NPI: 1629329719
Provider Name (Legal Business Name): CREEK ROAD DENTAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/28/2012
Last Update Date: 09/28/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7369 E CREEK RD
SANDY UT
84093-6154
US

IV. Provider business mailing address

7369 E CREEK RD
SANDY UT
84093-6154
US

V. Phone/Fax

Practice location:
  • Phone: 801-566-5577
  • Fax:
Mailing address:
  • Phone: 801-566-5577
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number590701-8903
License Number StateUT

VIII. Authorized Official

Name: DR. TYLER B CARLSON
Title or Position: MEMBER
Credential: DMD
Phone: 801-703-8947