1952659153 NPI number — LIFETIME DENTAL CARE OF MARYLAND, BADGER P.C.

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 1952659153 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:
KEY WEST CROSSING DENTAL ASSOCIATES
Provider Other Organization Name Type Code:
3
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:
1952659153
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:
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:
15020 SHADY GROVE RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ROCKVILLE
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
20850-3364
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
301-738-2111
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/17/2012

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: 122300000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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