Provider Demographics
NPI:1316962079
Name:COPPER CREEK DENTAL, PC
Entity type:Organization
Organization Name:COPPER CREEK DENTAL, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:J
Authorized Official - Last Name:STALEY
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:801-280-1911
Mailing Address - Street 1:3078 W 7800 S
Mailing Address - Street 2:STE 7-B
Mailing Address - City:WEST JORDAN
Mailing Address - State:UT
Mailing Address - Zip Code:84088-3707
Mailing Address - Country:US
Mailing Address - Phone:801-280-1911
Mailing Address - Fax:801-255-2394
Practice Address - Street 1:3078 W 7800 S
Practice Address - Street 2:STE 7-B
Practice Address - City:WEST JORDAN
Practice Address - State:UT
Practice Address - Zip Code:84088-3707
Practice Address - Country:US
Practice Address - Phone:801-280-1911
Practice Address - Fax:801-255-2394
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-13
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT373483-99221223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty