Provider Demographics
NPI:1063455129
Name:CRAIG R CAMERON DDS PLC
Entity Type:Organization
Organization Name:CRAIG R CAMERON DDS PLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:IT'S MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:CRAIG
Authorized Official - Middle Name:ROBERT
Authorized Official - Last Name:CAMERON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:231-853-6618
Mailing Address - Street 1:PO BOX 204
Mailing Address - Street 2:
Mailing Address - City:RAVENNA
Mailing Address - State:MI
Mailing Address - Zip Code:49451-0204
Mailing Address - Country:US
Mailing Address - Phone:231-853-6618
Mailing Address - Fax:231-853-2143
Practice Address - Street 1:12374 STAFFORD STREET
Practice Address - Street 2:
Practice Address - City:RAVENNA
Practice Address - State:MI
Practice Address - Zip Code:49451-0204
Practice Address - Country:US
Practice Address - Phone:231-853-6618
Practice Address - Fax:231-853-2143
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-14
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI134291223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4544163Medicaid