Provider Demographics
NPI:1063531572
Name:CENTRE DENTAL ASSOCIATES, P.C.
Entity type:Organization
Organization Name:CENTRE DENTAL ASSOCIATES, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:A
Authorized Official - Last Name:WILER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:269-323-3128
Mailing Address - Street 1:621 W CENTRE AVE
Mailing Address - Street 2:
Mailing Address - City:PORTAGE
Mailing Address - State:MI
Mailing Address - Zip Code:49024-5307
Mailing Address - Country:US
Mailing Address - Phone:269-323-3128
Mailing Address - Fax:269-323-2005
Practice Address - Street 1:621 W CENTRE AVE
Practice Address - Street 2:
Practice Address - City:PORTAGE
Practice Address - State:MI
Practice Address - Zip Code:49024-5307
Practice Address - Country:US
Practice Address - Phone:269-323-3128
Practice Address - Fax:269-323-2005
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-28
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI095721223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1619019700OtherDENTIST GENERAL PRACTICE