Healthcare Provider Details

I. General information

NPI: 1093206450
Provider Name (Legal Business Name): CREEK CAPITOL ORTHODONTICS- HUNTER PARK
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/22/2018
Last Update Date: 05/22/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2792 S 5600 W
WEST VALLEY UT
84120-5590
US

IV. Provider business mailing address

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

V. Phone/Fax

Practice location:
  • Phone: 801-969-9669
  • Fax:
Mailing address:
  • Phone: 801-918-4135
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number
License Number State

VIII. Authorized Official

Name: MARCI NICOL
Title or Position: COO
Credential:
Phone: 801-918-4135