1992899488 NPI number — LIFETIME DENTAL CARE OF MARYLAND, BADGER, P.C.

Table of content: MR. JEFFREY THOMAS BLUM PT (NPI 1760578926)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1992899488 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:
Provider Other Organization Name Type Code:
6
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:
1992899488
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/07/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
535 MAIN ST STE 113
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LAUREL
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
20707-4335
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
301-490-0044
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
535 MAIN STREET
Provider Second Line Business Practice Location Address:
SUITE 113
Provider Business Practice Location Address City Name:
LAUREL
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
20707-4335
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
301-490-0044
Provider Business Practice Location Address Fax Number:
301-497-1900
Provider Enumeration Date:
10/02/2006

Additional Information

Authorized Official

Authorized Official Last Name:
LEMKE
Authorized Official First Name:
TABATHA
Authorized Official Middle Name:
Authorized Official Title or Position:
CREDENTIALING COORDINATOR
Authorized Official Telephone Number:
217-540-6078

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X , with the licence number:  10680 , 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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