1679731145 NPI number — LIFETIME DENTAL CARE OF ILLINOIS, PC

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 1679731145 NPI number — LIFETIME DENTAL CARE OF ILLINOIS, PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LIFETIME DENTAL CARE OF ILLINOIS, PC
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:
Provider Other Organization Name Type Code:
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:
1679731145
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/30/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1200 NETWORK CENTRE DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
EFFINGHAM
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
62401-4637
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
217-540-5100
Provider Business Mailing Address Fax Number:
877-635-3298

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1200 NETWORK CENTRE DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
EFFINGHAM
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
62401-4637
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
217-540-5100
Provider Business Practice Location Address Fax Number:
877-635-3298
Provider Enumeration Date:
05/30/2008

Additional Information

Authorized Official

Authorized Official Last Name:
KROEGER
Authorized Official First Name:
AMY
Authorized Official Middle Name:
Authorized Official Title or Position:
INSURANCE COORDINATOR
Authorized Official Telephone Number:
217-540-5100

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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