Provider Demographics
NPI:1487862389
Name:BURTLESS-CREPS, CHAD (DDS)
Entity Type:Individual
Prefix:DR
First Name:CHAD
Middle Name:
Last Name:BURTLESS-CREPS
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 1:1331 OAKWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:ADRIAN
Mailing Address - State:MI
Mailing Address - Zip Code:49221-9691
Mailing Address - Country:US
Mailing Address - Phone:517-265-6254
Mailing Address - Fax:
Practice Address - Street 1:770 RIVERSIDE AVE
Practice Address - Street 2:SUITE #200
Practice Address - City:ADRIAN
Practice Address - State:MI
Practice Address - Zip Code:49221-1476
Practice Address - Country:US
Practice Address - Phone:517-263-9609
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI0137251223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice