MEDICARE: WILLOW DENTAL BELLEVUE, LLC

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	1223G0001X	General Practice Dentistry

General Provider Information

NPI Number	:	1366217051
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WILLOW DENTAL BELLEVUE, LLC

Provider Business Mailing Address
First Line	:	400 RIVERWALK TER STE 250
Second Line	:
City	:	JENKS
State	:	OK
Zip	:	74037-5619
Country	:	US
Telephone Number	:	918-998-0996
Fax Number	:	918-235-9079

Provider Business Practice Location Address
First Line	:	7511 S 36TH ST
Second Line	:
City	:	BELLEVUE
State	:	NE
Zip	:	68147-1244
Country	:	US
Telephone Number	:	402-733-2281
Fax Number	:	918-235-9079

Authorized Official
Title or Position	:	OWNER
Name	:	CREED CARDON
Credential	:
Telephone Number	:	918-998-0996

Provider Enumeration Date	:	11/22/2023
Last Update Date	:	11/22/2023

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