Provider Demographics
NPI:1386869790
Name:CHAD BURTLESS CREPS DDS PC
Entity type:Organization
Organization Name:CHAD BURTLESS CREPS DDS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:CHAD
Authorized Official - Middle Name:
Authorized Official - Last Name:BURTLESS CREPS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:517-263-9609
Mailing Address - Street 1:770 RIVERSIDE AVENUE
Mailing Address - Street 2:SUITE 200
Mailing Address - City:ADRIAN
Mailing Address - State:MI
Mailing Address - Zip Code:49221
Mailing Address - Country:US
Mailing Address - Phone:517-263-9609
Mailing Address - Fax:517-265-7710
Practice Address - Street 1:770 RIVERSIDE AVENUE
Practice Address - Street 2:SUITE 200
Practice Address - City:ADRIAN
Practice Address - State:MI
Practice Address - Zip Code:49221
Practice Address - Country:US
Practice Address - Phone:517-263-9609
Practice Address - Fax:517-265-7710
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-13
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2901013725122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty