1972892214 NPI number — LIFETIME FAMILY DENTISTRY OF TWO RIVERS

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 1972892214 NPI number — LIFETIME FAMILY DENTISTRY OF TWO RIVERS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LIFETIME FAMILY DENTISTRY OF TWO RIVERS
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:
1972892214
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/06/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1509 19TH ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TWO RIVERS
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
54241-2628
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
920-794-8947
Provider Business Mailing Address Fax Number:
920-793-8463

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1509 19TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TWO RIVERS
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
54241-2628
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
920-794-8947
Provider Business Practice Location Address Fax Number:
920-793-8463
Provider Enumeration Date:
04/06/2011

Additional Information

Authorized Official

Authorized Official Last Name:
BUCK
Authorized Official First Name:
TIMOTHY
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
608-220-1168

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X , with the licence number:  3639015 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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