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General NPI Number Information
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NPI Number | 1306357447
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Entity Type | Organization
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Legal Business Name | COUNTRY CREEK DENTAL PLLC
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Dates
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Enumeration Date | 10/16/2017
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Last Update Date | 10/16/2017
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Provider Practice Location Address
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Address Line | 207 KINGS CT
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City | ALCOA
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State | TN
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Zip | 37701-1939
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Country | US
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Telephone | 865-983-6361
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Fax |
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Provider Business Mailing Address
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Address Line | 7605 GILMORE LN
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City | CORRYTON
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State | TN
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Zip | 37721-4128
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Country | US
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Telephone | 775-291-0075
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Fax |
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Authorized Official
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Title or Position | DENTIST
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Name | DR. NATHAN LA MONICA
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Credential | DMD
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Telephone | 775-291-0075
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QD0000X
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Taxonomy Name | Dental Clinic/Center
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License Number | 10031
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License Number State | TN
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