Provider Demographics
NPI:1285982025
Name:CREEKSIDE DENTAL LLC
Entity type:Organization
Organization Name:CREEKSIDE DENTAL LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:ROLLIN
Authorized Official - Last Name:MCCOLLEY
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:307-674-9222
Mailing Address - Street 1:642 VAL VISTA ST
Mailing Address - Street 2:STUITE #A
Mailing Address - City:SHERIDAN
Mailing Address - State:WY
Mailing Address - Zip Code:82801-3659
Mailing Address - Country:US
Mailing Address - Phone:307-674-9222
Mailing Address - Fax:307-674-1765
Practice Address - Street 1:642 VAL VISTA ST
Practice Address - Street 2:STUITE #A
Practice Address - City:SHERIDAN
Practice Address - State:WY
Practice Address - Zip Code:82801-3659
Practice Address - Country:US
Practice Address - Phone:307-674-9222
Practice Address - Fax:307-674-1765
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-08-28
Last Update Date:2014-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty