MEDICARE: CREEKWOOD DENTAL ARTS, PLLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QD0000X	Dental Clinic/Center

General Provider Information

NPI Number	:	1235735218
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CREEKWOOD DENTAL ARTS, PLLC

Provider Business Mailing Address
First Line	:	7911 WOODWAY DR
Second Line	:
City	:	WACO
State	:	TX
Zip	:	76712-3866
Country	:	US
Telephone Number	:	254-772-3632
Fax Number	:	254-772-7856

Provider Business Practice Location Address
First Line	:	7911 WOODWAY DR
Second Line	:
City	:	WACO
State	:	TX
Zip	:	76712-3866
Country	:	US
Telephone Number	:	254-772-3632
Fax Number	:	254-772-7856

Authorized Official
Title or Position	:	DENTIST
Name	:	DR. AUSTIN REVVIE GREEN
Credential	:	DDS
Telephone Number	:	254-772-3632

Provider Enumeration Date	:	12/07/2020
Last Update Date	:	12/07/2020

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