1669880845 NPI number — LIFETIME DENTAL PARTNERS, PLLC

Table of content: (NPI 1669880845)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1669880845 NPI number — LIFETIME DENTAL PARTNERS, PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LIFETIME DENTAL PARTNERS, 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:
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:
1669880845
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/11/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
927 W 12TH ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GRAFTON
Provider Business Mailing Address State Name:
ND
Provider Business Mailing Address Postal Code:
58237-2121
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
701-352-2450
Provider Business Mailing Address Fax Number:
701-352-2424

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
321 BRIGGS AVE S
Provider Second Line Business Practice Location Address:
SUITE 3
Provider Business Practice Location Address City Name:
PARK RIVER
Provider Business Practice Location Address State Name:
ND
Provider Business Practice Location Address Postal Code:
58270
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
701-284-7777
Provider Business Practice Location Address Fax Number:
701-284-6776
Provider Enumeration Date:
07/31/2014

Additional Information

Authorized Official

Authorized Official Last Name:
EKMAN
Authorized Official First Name:
ROBERTA
Authorized Official Middle Name:
LEA
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
701-352-2450

Provider Taxonomy Codes

  • Taxonomy code: 261QD0000X , with the licence number:  1904 , registered in the state of ND ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1458306 , issued by the state of ( ND ) . This identifiers is of the category "MEDICAID".




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