Healthcare Provider Details

I. General information

NPI: 1124884366
Provider Name (Legal Business Name): CRESCENT LAKE DENTAL CARE PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/26/2024
Last Update Date: 02/26/2024
Certification Date: 02/26/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

998 CRESCENT LAKE RD
WATERFORD MI
48327-2594
US

IV. Provider business mailing address

1849 N DENWOOD ST
DEARBORN MI
48128-1156
US

V. Phone/Fax

Practice location:
  • Phone: 248-682-9331
  • Fax:
Mailing address:
  • Phone:
  • 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: MOHAMMED SOBH
Title or Position: OWNER/DOCTOR
Credential: DDS
Phone: 313-663-6484