=====================================================
General NPI Number Information
=====================================================
NPI Number | 1023481736
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CREEKSIDE FAMILY DENTAL
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/03/2015
-----------------------------------------------------
Last Update Date | 11/03/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 111 W JOHNSTOWN RD SUITE A
-----------------------------------------------------
City | GAHANNA
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 43230-3515
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 614-471-5090
-----------------------------------------------------
Fax | 614-471-5277
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 111 W JOHNSTOWN RD SUITE A
-----------------------------------------------------
City | GAHANNA
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 43230-3515
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 614-471-5090
-----------------------------------------------------
Fax | 614-471-5277
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DENTIST
-----------------------------------------------------
Name | DR. WILLIAM WARREN LEFFLER
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 614-471-5090
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 30-023480
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------