Provider Demographics
NPI:1164821708
Name:LIFETIME DENTAL PROFESSIONALS OF NEW HAMPSHIRE, P.C.
Entity Type:Organization
Organization Name:LIFETIME DENTAL PROFESSIONALS OF NEW HAMPSHIRE, P.C.
Other - Org Name:EAST ROCHESTER FAMILY DENTISTRY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CRED. SUPERVISOR
Authorized Official - Prefix:
Authorized Official - First Name:KIM
Authorized Official - Middle Name:
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:217-540-5170
Mailing Address - Street 1:152 HIGHLAND ST
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NH
Mailing Address - Zip Code:03868-8507
Mailing Address - Country:US
Mailing Address - Phone:603-332-8868
Mailing Address - Fax:
Practice Address - Street 1:152 HIGHLAND ST
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NH
Practice Address - Zip Code:03868-8507
Practice Address - Country:US
Practice Address - Phone:603-332-8868
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LIFETIME DENTAL PROFESSIONALS OF NEW HAMPSHIRE, P.C.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-08-20
Last Update Date:2014-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty