Provider Demographics
NPI:1306506100
Name:CRESTWOOD DENTAL ON THE LAKE, PLC
Entity type:Organization
Organization Name:CRESTWOOD DENTAL ON THE LAKE, PLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:J
Authorized Official - Last Name:ABDELMESSIH
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:248-800-4140
Mailing Address - Street 1:1363 ROCHESTER RD
Mailing Address - Street 2:
Mailing Address - City:LEONARD
Mailing Address - State:MI
Mailing Address - Zip Code:48367-6607
Mailing Address - Country:US
Mailing Address - Phone:248-800-4140
Mailing Address - Fax:
Practice Address - Street 1:1363 ROCHESTER RD
Practice Address - Street 2:
Practice Address - City:LEONARD
Practice Address - State:MI
Practice Address - Zip Code:48367-6607
Practice Address - Country:US
Practice Address - Phone:248-800-4140
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-12-21
Last Update Date:2021-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental