Provider Demographics
NPI:1487866919
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 1:7310 N. VILLA LAKE DRIVE
Mailing Address - Street 2:SUITE B
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61614
Mailing Address - Country:US
Mailing Address - Phone:309-691-9072
Mailing Address - Fax:309-691-9432
Practice Address - Street 1:7310 N. VILLA LAKE DRIVE
Practice Address - Street 2:SUITE B
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61614
Practice Address - Country:US
Practice Address - Phone:309-691-9072
Practice Address - Fax:309-691-9432
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LIFETIME DENTAL CARE OF ILLINOIS, PC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-05-04
Last Update Date:2008-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty