Provider Demographics
NPI:1053533372
Name:LIFETIME DENTAL CARE OF ILLINOIS, PC
Entity type:Organization
Organization Name:LIFETIME DENTAL CARE OF ILLINOIS, 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 1:5953 NORTH ILLINOIS STREET
Mailing Address - Street 2:
Mailing Address - City:FAIRVIEW HEIGHTS
Mailing Address - State:IL
Mailing Address - Zip Code:62208
Mailing Address - Country:US
Mailing Address - Phone:618-233-6700
Mailing Address - Fax:618-233-6701
Practice Address - Street 1:5953 NORTH ILLINOIS STREET
Practice Address - Street 2:
Practice Address - City:FAIRVIEW HEIGHTS
Practice Address - State:IL
Practice Address - Zip Code:62208
Practice Address - Country:US
Practice Address - Phone:618-233-6700
Practice Address - Fax:618-233-6701
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LIFETIME DENTAL CARE OF ILLINOIS, PC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-05-03
Last Update Date:2008-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty