Provider Demographics
NPI:1568629665
Name:CZARNECKI, GREGORY (GREG CZARNECKI)
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:
Last Name:CZARNECKI
Suffix:
Gender:M
Credentials:GREG CZARNECKI
Other - Prefix:
Other - First Name:GREG
Other - Middle Name:
Other - Last Name:CZARNECKI
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:GREG CZARNECKI
Mailing Address - Street 1:22190 GARRISON ST
Mailing Address - Street 2:302
Mailing Address - City:DEARBORN
Mailing Address - State:MI
Mailing Address - Zip Code:48124-2260
Mailing Address - Country:US
Mailing Address - Phone:313-562-0255
Mailing Address - Fax:
Practice Address - Street 1:22190 GARRISON ST
Practice Address - Street 2:302
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48124-2260
Practice Address - Country:US
Practice Address - Phone:313-562-0255
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-18
Last Update Date:2008-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29010117921223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice