Provider Demographics
NPI:1174032932
Name:LIFETIME DENTAL CARE OF MICHIGAN, P.C.
Entity Type:Organization
Organization Name:LIFETIME DENTAL CARE OF MICHIGAN, P.C.
Other - Org Name:LANSING ELITE DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:CASSANDRA
Authorized Official - Middle Name:
Authorized Official - Last Name:PETERSEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:217-540-8972
Mailing Address - Street 1:4912 W ST JOE HWY
Mailing Address - Street 2:
Mailing Address - City:LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48917-4090
Mailing Address - Country:US
Mailing Address - Phone:517-481-4170
Mailing Address - Fax:
Practice Address - Street 1:4912 W ST JOE HWY
Practice Address - Street 2:
Practice Address - City:LANSING
Practice Address - State:MI
Practice Address - Zip Code:48917-4090
Practice Address - Country:US
Practice Address - Phone:517-481-4170
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:2017-09-25
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty