Provider Demographics
NPI:1942038880
Name:LIFETIME DENTAL CARE OF MICHIGAN, P.C.
Entity type:Organization
Organization Name:LIFETIME DENTAL CARE OF MICHIGAN, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:CEMYIRA
Authorized Official - Middle Name:
Authorized Official - Last Name:MCDOUGAL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:217-764-8609
Mailing Address - Street 1:7924 SECOR RD
Mailing Address - Street 2:
Mailing Address - City:LAMBERTVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:48144-9619
Mailing Address - Country:US
Mailing Address - Phone:734-856-3004
Mailing Address - Fax:
Practice Address - Street 1:7924 SECOR RD
Practice Address - Street 2:
Practice Address - City:LAMBERTVILLE
Practice Address - State:MI
Practice Address - Zip Code:48144-9619
Practice Address - Country:US
Practice Address - Phone:734-856-3004
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LIFETIME DENTAL CARE OF MICHIGAN, P.C.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2024-07-23
Last Update Date:2024-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty