1356365910 NPI number — LIFETIME DENTAL CARE OF MARYLAND, BADGER, P.C.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1356365910 NPI number — LIFETIME DENTAL CARE OF MARYLAND, BADGER, P.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LIFETIME DENTAL CARE OF MARYLAND, BADGER, P.C.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
DENTAL PROFESSIONALS OF MARYLAND, GERALD AWADZI, PC
Provider Other Organization Name Type Code:
4
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1356365910
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/13/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1200 NETWORK CENTRE DRIVE
Provider Second Line Business Mailing Address:
SUITE #2
Provider Business Mailing Address City Name:
EFFINGHAM
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
62401
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
217-540-8946
Provider Business Mailing Address Fax Number:
217-540-8946

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
11301 ROCKVILLE PIKE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
KENSINGTON
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
20895-1060
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
301-770-1200
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/27/2006

Additional Information

Authorized Official

Authorized Official Last Name:
HOWARD
Authorized Official First Name:
BRITTANY
Authorized Official Middle Name:
NICHELLE
Authorized Official Title or Position:
CREDENTIALING AFFILIATION COORDINAT
Authorized Official Telephone Number:
217-540-8946

Provider Taxonomy Codes

  • Taxonomy code: 122300000X , with the licence number:  11918 , registered in the state of MD ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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