Healthcare Provider Details

I. General information

NPI: 1851889471
Provider Name (Legal Business Name): LAKE ODESSA DENTAL, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/30/2018
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: 616-560-3625
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. MICHAEL JOSEPH CRETE
Title or Position: MEMBER
Credential: DDS
Phone: 616-560-3625