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General NPI Number Information
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NPI Number | 1790418754
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Entity Type | Organization
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Legal Business Name | CLEAR CREEK FAMILY DENTAL
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Dates
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Enumeration Date | 07/07/2022
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Last Update Date | 07/07/2022
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Provider Practice Location Address
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Address Line | 101 S STATE HIGHWAY 125 STE A
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City | STRAFFORD
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State | MO
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Zip | 65757-8998
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Country | US
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Telephone | 417-631-4490
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Fax | 417-736-9250
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Provider Business Mailing Address
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Address Line | 101 S STATE HIGHWAY 125 STE A
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City | STRAFFORD
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State | MO
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Zip | 65757-8998
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Country | US
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Telephone | 417-631-4490
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Fax | 417-736-9250
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Authorized Official
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Title or Position | OFFICE MANAGER
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Name | BRIANNA ROSE NICHOLS
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Credential |
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Telephone | 417-350-6045
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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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