=====================================================
General NPI Number Information
=====================================================
NPI Number | 1528432150
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DENTISTRY OF CREEKSIDE PARK, PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/19/2015
-----------------------------------------------------
Last Update Date | 11/19/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 26400 KUYKENDAHL RD SUITE C210
-----------------------------------------------------
City | TOMBALL
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77375-2882
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 281-351-2055
-----------------------------------------------------
Fax | 281-351-2066
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 26400 KUYKENDAHL RD SUITE C210
-----------------------------------------------------
City | TOMBALL
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77375-2882
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 281-351-2055
-----------------------------------------------------
Fax | 281-351-2066
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/DENTIST
-----------------------------------------------------
Name | DR. CHRISTOPHER S ANTON
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 281-351-2055
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QD0000X
-----------------------------------------------------
Taxonomy Name | Dental Clinic/Center
-----------------------------------------------------
License Number | 20978
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------