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General NPI Number Information
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NPI Number | 1043955412
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Entity Type | Organization
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Legal Business Name | CREEKSIDE DENTAL PLLC
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Dates
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Enumeration Date | 05/01/2022
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Last Update Date | 05/01/2022
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Provider Practice Location Address
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Address Line | 3340 REPUBLIC AVE STE 130
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City | ST LOUIS PARK
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State | MN
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Zip | 55426-4189
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Country | US
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Telephone | 763-442-7624
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Fax |
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Provider Business Mailing Address
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Address Line | 12445 PORCUPINE CT
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City | EDEN PRAIRIE
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State | MN
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Zip | 55344-3972
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Country | US
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Telephone | 612-327-3331
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Fax |
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Authorized Official
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Title or Position | OWNER/DENTIST
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Name | DR. GABRIEL DE LOS RIOS
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Credential | DDS
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Telephone | 763-442-7624
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number |
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License Number State |
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