Provider Demographics
NPI:1376756635
Name:LIFETIME DENTAL CARE OF ILLINOIS, PC
Entity Type:Organization
Organization Name:LIFETIME DENTAL CARE OF ILLINOIS, PC
Other - Org Name:GREEN MOUNT FAMILY DENTISTRY
Other - Org Type:Doing Business As
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 1:1490 NORTH GREENMOUNT ROAD
Mailing Address - Street 2:SUITE A
Mailing Address - City:OFALLON
Mailing Address - State:IL
Mailing Address - Zip Code:62269
Mailing Address - Country:US
Mailing Address - Phone:618-622-9720
Mailing Address - Fax:618-622-1700
Practice Address - Street 1:1490 NORTH GREENMOUNT ROAD
Practice Address - Street 2:SUITE A
Practice Address - City:OFALLON
Practice Address - State:IL
Practice Address - Zip Code:62269
Practice Address - Country:US
Practice Address - Phone:618-622-9720
Practice Address - Fax:618-622-1700
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LIFETIME DENTAL CARE OF ILLINOIS, PC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-05-07
Last Update Date:2008-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty