Provider Demographics
NPI:1073785754
Name:MAXWELL, CARLA MARIE
Entity Type:Individual
Prefix:DR
First Name:CARLA
Middle Name:MARIE
Last Name:MAXWELL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 E LONG LAKE
Mailing Address - Street 2:STE 311 CREST EXPRESSIONS DENTAL CENTERS
Mailing Address - City:BLOOMFIELD HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48304
Mailing Address - Country:US
Mailing Address - Phone:248-203-1119
Mailing Address - Fax:248-723-0052
Practice Address - Street 1:5958 CANTON CENTER RD
Practice Address - Street 2:STE 400 CREST EXPRESSIONS DENTAL CENTERS
Practice Address - City:BLOOMFIELD HILLS
Practice Address - State:MI
Practice Address - Zip Code:48304
Practice Address - Country:US
Practice Address - Phone:234-451-9570
Practice Address - Fax:734-451-9574
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-02
Last Update Date:2008-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2901018110122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist