Provider Demographics
NPI:1306488382
Name:MALLARD CREEK FAMILY DENTISTRY LLP
Entity type:Organization
Organization Name:MALLARD CREEK FAMILY DENTISTRY LLP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:SUZI
Authorized Official - Middle Name:
Authorized Official - Last Name:WALLACE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:704-596-0021
Mailing Address - Street 1:3010 BAUCOM RD STE 200
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28269-6765
Mailing Address - Country:US
Mailing Address - Phone:704-596-0021
Mailing Address - Fax:704-599-1155
Practice Address - Street 1:3010 BAUCOM RD STE 200
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28269-6765
Practice Address - Country:US
Practice Address - Phone:704-596-0021
Practice Address - Fax:704-599-1155
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-10-11
Last Update Date:2019-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty