MEDICARE: LAKE ODESSA DENTAL, PLLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QD0000X	Dental Clinic/Center

General Provider Information

NPI Number	:	1851889471
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LAKE ODESSA DENTAL, PLLC

Provider Business Mailing Address
First Line	:	2101 SAN LU RAE DR SE
Second Line	:
City	:	GRAND RAPIDS
State	:	MI
Zip	:	49506-3425
Country	:	US
Telephone Number	:	616-560-3625
Fax Number	:

Provider Business Practice Location Address
First Line	:	1032 4TH AVE
Second Line	:
City	:	LAKE ODESSA
State	:	MI
Zip	:	48849-1004
Country	:	US
Telephone Number	:	616-374-8828
Fax Number	:	616-374-7934

Authorized Official
Title or Position	:	MEMBER
Name	:	DR. MICHAEL JOSEPH CRETE
Credential	:	DDS
Telephone Number	:	616-560-3625

Provider Enumeration Date	:	04/30/2018
Last Update Date	:	04/30/2018

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