1053573725 NPI number — LIFETIME DENTAL PLLC

Table of content: (NPI 1053573725)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1053573725 NPI number — LIFETIME DENTAL PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LIFETIME DENTAL PLLC
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:
JOHNSON DENTAL CLINIC
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:
1053573725
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/23/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1313 W HIGHWAY 8
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CLEVELAND
Provider Business Mailing Address State Name:
MS
Provider Business Mailing Address Postal Code:
38732-2240
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
662-843-8353
Provider Business Mailing Address Fax Number:
662-843-8363

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1313 W HIGHWAY 8
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CLEVELAND
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
38732-2240
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
662-843-8353
Provider Business Practice Location Address Fax Number:
662-843-8363
Provider Enumeration Date:
06/25/2008

Additional Information

Authorized Official

Authorized Official Last Name:
BROWN
Authorized Official First Name:
HAMILTON
Authorized Official Middle Name:
M
Authorized Official Title or Position:
PARTNER
Authorized Official Telephone Number:
662-843-8353

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X , with the licence number:  2826-94 , registered in the state of MS ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 09015931 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2024 www.npivalidator.com