Provider Demographics
NPI:1871647685
Name:CRESSWELL, JACQUELINE JEAN (DDS)
Entity Type:Individual
Prefix:DR
First Name:JACQUELINE
Middle Name:JEAN
Last Name:CRESSWELL
Suffix:
Gender:F
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:PO BOX 305
Mailing Address - Street 2:
Mailing Address - City:WEST BRANCH
Mailing Address - State:MI
Mailing Address - Zip Code:48661-0305
Mailing Address - Country:US
Mailing Address - Phone:989-345-4464
Mailing Address - Fax:
Practice Address - Street 1:220 W GARFIELD AVE
Practice Address - Street 2:
Practice Address - City:CHARLEVOIX
Practice Address - State:MI
Practice Address - Zip Code:49720-1631
Practice Address - Country:US
Practice Address - Phone:231-547-6523
Practice Address - Fax:231-547-6238
Is Sole Proprietor?:No
Enumeration Date:2007-01-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI11790122300000X
IL16459122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4625717Medicaid