Provider Demographics
NPI:1053523159
Name:LIFETIME DENTAL CARE OF INDIANA, PC
Entity type:Organization
Organization Name:LIFETIME DENTAL CARE OF INDIANA, PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:INS COOD
Authorized Official - Prefix:
Authorized Official - First Name:AMY
Authorized Official - Middle Name:
Authorized Official - Last Name:KROEGER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:217-540-5100
Mailing Address - Street 1:3915 SOUTH MADISON AVE
Mailing Address - Street 2:SUITE 2
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46227
Mailing Address - Country:US
Mailing Address - Phone:317-788-1001
Mailing Address - Fax:317-788-1290
Practice Address - Street 1:3915 SOUTH MADISON AVE
Practice Address - Street 2:SUITE 2
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46227
Practice Address - Country:US
Practice Address - Phone:317-788-1001
Practice Address - Fax:317-788-1290
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-03
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty