Provider Demographics
NPI:1780804559
Name:MARCINIAK, CRYSTAL LYNN
Entity type:Individual
Prefix:DR
First Name:CRYSTAL
Middle Name:LYNN
Last Name:MARCINIAK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:110 CALHOUN AVE
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:MI
Mailing Address - Zip Code:49236-9459
Mailing Address - Country:US
Mailing Address - Phone:517-456-6568
Mailing Address - Fax:
Practice Address - Street 1:9178 E US HIGHWAY 223
Practice Address - Street 2:
Practice Address - City:BLISSFIELD
Practice Address - State:MI
Practice Address - Zip Code:49228-9665
Practice Address - Country:US
Practice Address - Phone:517-486-2030
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-26
Last Update Date:2007-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29010193161223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice