Provider Demographics
NPI:1538905278
Name:COLUMBIA FAMILY DENTAL, LLC
Entity type:Organization
Organization Name:COLUMBIA FAMILY DENTAL, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:CARDON
Authorized Official - Middle Name:
Authorized Official - Last Name:CREED
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:918-998-0996
Mailing Address - Street 1:400 RIVERWALK TER STE 250
Mailing Address - Street 2:
Mailing Address - City:JENKS
Mailing Address - State:OK
Mailing Address - Zip Code:74037-5619
Mailing Address - Country:US
Mailing Address - Phone:918-998-0996
Mailing Address - Fax:918-235-9079
Practice Address - Street 1:2718 FORUM BLVD STE 1
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MO
Practice Address - Zip Code:65203-5451
Practice Address - Country:US
Practice Address - Phone:573-446-1775
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-07-02
Last Update Date:2024-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty