Provider Demographics
NPI:1740558139
Name:CREATIVE DENTAL CENTER PC
Entity Type:Organization
Organization Name:CREATIVE DENTAL CENTER PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:A
Authorized Official - Last Name:KOHN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:586-751-6617
Mailing Address - Street 1:28225 HOOVER RD
Mailing Address - Street 2:
Mailing Address - City:WARREN
Mailing Address - State:MI
Mailing Address - Zip Code:48093-5436
Mailing Address - Country:US
Mailing Address - Phone:586-751-6617
Mailing Address - Fax:586-751-6264
Practice Address - Street 1:28225 HOOVER RD
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:MI
Practice Address - Zip Code:48093-5436
Practice Address - Country:US
Practice Address - Phone:586-751-6617
Practice Address - Fax:586-751-6264
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-12-13
Last Update Date:2011-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI0151921223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty