Provider Demographics
NPI:1992586143
Name:CREEKSIDE ORAL SURGERY INC
Entity type:Organization
Organization Name:CREEKSIDE ORAL SURGERY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:NKEMAKONAM
Authorized Official - Middle Name:
Authorized Official - Last Name:EGOLUM
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:770-764-0840
Mailing Address - Street 1:10700 MEDLOCK BRIDGE RD STE 204
Mailing Address - Street 2:
Mailing Address - City:JOHNS CREEK
Mailing Address - State:GA
Mailing Address - Zip Code:30097-8455
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:10700 MEDLOCK BRIDGE RD STE 204
Practice Address - Street 2:
Practice Address - City:JOHNS CREEK
Practice Address - State:GA
Practice Address - Zip Code:30097-8455
Practice Address - Country:US
Practice Address - Phone:770-764-0840
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-10-12
Last Update Date:2023-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty