Provider Demographics
NPI:1790831402
Name:CRETE, MICHAEL J (DDS)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:J
Last Name:CRETE
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 1:2101 SAN LU RAE DR SE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49506-3425
Mailing Address - Country:US
Mailing Address - Phone:616-374-8828
Mailing Address - Fax:616-374-7934
Practice Address - Street 1:1032 4TH AVE
Practice Address - Street 2:
Practice Address - City:LAKE ODESSA
Practice Address - State:MI
Practice Address - Zip Code:48849-1004
Practice Address - Country:US
Practice Address - Phone:616-374-8828
Practice Address - Fax:616-374-7934
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-26
Last Update Date:2018-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI143931223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice