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General NPI Number Information
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NPI Number | 1285982025
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Entity Type | Organization
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Legal Business Name | CREEKSIDE DENTAL LLC
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Dates
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Enumeration Date | 08/28/2012
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Last Update Date | 12/31/2014
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Provider Practice Location Address
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Address Line | 642 VAL VISTA ST STUITE #A
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City | SHERIDAN
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State | WY
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Zip | 82801-3659
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Country | US
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Telephone | 307-674-9222
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Fax | 307-674-1765
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Provider Business Mailing Address
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Address Line | 642 VAL VISTA ST STUITE #A
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City | SHERIDAN
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State | WY
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Zip | 82801-3659
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Country | US
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Telephone | 307-674-9222
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Fax | 307-674-1765
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Authorized Official
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Title or Position | OWNER/DENTIST
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Name | DR. JOSEPH ROLLIN MCCOLLEY
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Credential | D.D.S
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Telephone | 307-674-9222
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number |
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License Number State |
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