Provider Demographics
NPI:1588675607
Name:WILLOW CREEK DENTAL CLINIC, PC
Entity Type:Organization
Organization Name:WILLOW CREEK DENTAL CLINIC, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JACK
Authorized Official - Middle Name:
Authorized Official - Last Name:FALVO
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:734-981-5455
Mailing Address - Street 1:5970 N LILLEY RD
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:MI
Mailing Address - Zip Code:48187-3625
Mailing Address - Country:US
Mailing Address - Phone:734-981-5455
Mailing Address - Fax:734-981-0370
Practice Address - Street 1:5970 N LILLEY RD
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:MI
Practice Address - Zip Code:48187-3625
Practice Address - Country:US
Practice Address - Phone:734-981-5455
Practice Address - Fax:734-981-0370
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-11
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI110381223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MID8014557OtherBLUE CROSS BLUE SHIELD
MI4045655Medicaid
MI4784419Medicaid
MI972811OtherUCCI
MI4648480Medicaid
MI4044756Medicaid
MI4876118Medicaid
MI4876118Medicaid