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General NPI Number Information
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NPI Number | 1316553860
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Entity Type | Organization
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Legal Business Name | WILLOW CREEK PERFECT TEETH PC
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Dates
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Enumeration Date | 09/21/2020
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Last Update Date | 09/21/2020
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Provider Practice Location Address
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Address Line | 8150 S QUEBEC ST STE C
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City | CENTENNIAL
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State | CO
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Zip | 80112-3186
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Country | US
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Telephone | 720-728-6530
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Fax |
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Provider Business Mailing Address
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Address Line | 7160 DALLAS PKWY STE 400
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City | PLANO
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State | TX
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Zip | 75024-7111
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Country | US
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Telephone | 720-441-3423
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Fax |
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Authorized Official
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Title or Position | CREDENTIALING MANAGER
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Name | DIANE MARIE BRION-MARTIN
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Credential |
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Telephone | 720-441-3423
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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 |
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License Number State |
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