1780011221 NPI number — SPRING CREEK DENTAL PLLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1780011221 NPI number — SPRING CREEK DENTAL PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SPRING CREEK DENTAL PLLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1780011221
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/16/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2001 S SHIELDS ST
Provider Second Line Business Mailing Address:
BLDG C1
Provider Business Mailing Address City Name:
FORT COLLINS
Provider Business Mailing Address State Name:
CO
Provider Business Mailing Address Postal Code:
80526-1827
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
970-482-8883
Provider Business Mailing Address Fax Number:
970-484-9278

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2001 SOUTH SHIELDS STREET
Provider Second Line Business Practice Location Address:
BLDG. C-1
Provider Business Practice Location Address City Name:
FORT COLLINS
Provider Business Practice Location Address State Name:
CO
Provider Business Practice Location Address Postal Code:
80526
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
970-482-8883
Provider Business Practice Location Address Fax Number:
970-484-9278
Provider Enumeration Date:
09/30/2013

Additional Information

Authorized Official

Authorized Official Last Name:
KAINES
Authorized Official First Name:
JOEL
Authorized Official Middle Name:
ROBERT
Authorized Official Title or Position:
DENTIST/OWNER
Authorized Official Telephone Number:
970-482-8883

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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