Provider Demographics
NPI:1679024442
Name:LIFETIME DENTAL LLC
Entity type:Organization
Organization Name:LIFETIME DENTAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE PROPRIETOR
Authorized Official - Prefix:
Authorized Official - First Name:DARYL
Authorized Official - Middle Name:LANCE
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:662-843-8353
Mailing Address - Street 1:1313 W HIGHWAY 8
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:MS
Mailing Address - Zip Code:38732-2240
Mailing Address - Country:US
Mailing Address - Phone:662-843-8353
Mailing Address - Fax:662-843-8363
Practice Address - Street 1:910 MEDALLION DR
Practice Address - Street 2:
Practice Address - City:GREENWOOD
Practice Address - State:MS
Practice Address - Zip Code:38930-2118
Practice Address - Country:US
Practice Address - Phone:662-843-8353
Practice Address - Fax:662-843-8363
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:JOHNSON DENTAL CLINIC INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-10-17
Last Update Date:2016-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS2826-94122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS09015931Medicaid