1619032620 NPI number — LIFETIME DENTAL CARE OF MARYLAND, BADGER, P.C.

Table of content: (NPI 1619032620)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1619032620 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:
1619032620
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:
2191 DEFENSE HWY #210
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CROFTON
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
21114
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
410-721-2610
Provider Business Practice Location Address Fax Number:
410-721-8053
Provider Enumeration Date:
12/27/2006

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 ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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