Basic Information
| Provider Information | |||||||||
| NPI: | 1568917888 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CREEKSIDE DENTAL | ||||||||
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| Mailing Information | |||||||||
| Address1: | 910 NE TENNEY RD STE 117 | ||||||||
| Address2: | |||||||||
| City: | VANCOUVER | ||||||||
| State: | WA | ||||||||
| PostalCode: | 986852838 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3606951515 | ||||||||
| FaxNumber: | 3606948449 | ||||||||
| Practice Location | |||||||||
| Address1: | 910 NE TENNEY RD STE 117 | ||||||||
| Address2: | |||||||||
| City: | VANCOUVER | ||||||||
| State: | WA | ||||||||
| PostalCode: | 986852838 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3606951515 | ||||||||
| FaxNumber: | 3606948449 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/16/2016 | ||||||||
| LastUpdateDate: | 08/16/2016 | ||||||||
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| AuthorizedOfficialLastName: | HANSON | ||||||||
| AuthorizedOfficialFirstName: | DAVID | ||||||||
| AuthorizedOfficialMiddleName: | LEWIS | ||||||||
| AuthorizedOfficialTitleorPosition: | DENTIST/OWNER | ||||||||
| AuthorizedOfficialTelephone: | 3606951515 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | DDS | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | 6279 | WA | Y | 193400000X SINGLE SPECIALTY GROUP | Dental Providers | Dentist | General Practice |
No ID Information.