MEDICARE: CLEAR CREEK DENTAL

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	:	1861634586
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CLEAR CREEK DENTAL

Provider Business Mailing Address
First Line	:	6364 MAIN ST
Second Line	:
City	:	NORTH BRANCH
State	:	MN
Zip	:	55056-6693
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	6364 MAIN ST
Second Line	:
City	:	NORTH BRANCH
State	:	MN
Zip	:	55056-6693
Country	:	US
Telephone Number	:	651-674-8128
Fax Number	:

Authorized Official
Title or Position	:	CONTACT OFFICER
Name	:	GENIE KUBLE
Credential	:
Telephone Number	:	920-450-0157

Provider Enumeration Date	:	03/26/2009
Last Update Date	:	03/26/2009

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Directions to “CLEAR CREEK DENTAL ” Practice Location

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