Provider Demographics
NPI:1003983677
Name:MIRKIN, CRAIG (DDS)
Entity Type:Individual
Prefix:
First Name:CRAIG
Middle Name:
Last Name:MIRKIN
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3415 28TH ST
Mailing Address - Street 2:
Mailing Address - City:PORT HURON
Mailing Address - State:MI
Mailing Address - Zip Code:48060-6931
Mailing Address - Country:US
Mailing Address - Phone:810-984-5197
Mailing Address - Fax:810-985-2150
Practice Address - Street 1:3415 28TH ST
Practice Address - Street 2:
Practice Address - City:PORT HURON
Practice Address - State:MI
Practice Address - Zip Code:48060-6931
Practice Address - Country:US
Practice Address - Phone:810-984-5197
Practice Address - Fax:810-985-2150
Is Sole Proprietor?:No
Enumeration Date:2006-11-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29010111801223D0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223D0001XDental ProvidersDentistDental Public Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4046170Medicaid