Healthcare Provider Details

I. General information

NPI: 1790831402
Provider Name (Legal Business Name): MICHAEL J CRETE DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/26/2007
Last Update Date: 04/30/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1032 4TH AVE
LAKE ODESSA MI
48849-1004
US

IV. Provider business mailing address

2101 SAN LU RAE DR SE
GRAND RAPIDS MI
49506-3425
US

V. Phone/Fax

Practice location:
  • Phone: 616-374-8828
  • Fax: 616-374-7934
Mailing address:
  • Phone: 616-374-8828
  • Fax: 616-374-7934

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number14393
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: