Provider Demographics
NPI:1376930644
Name:LIFETIME DENTISTRY
Entity Type:Organization
Organization Name:LIFETIME DENTISTRY
Other - Org Name:LIFETIME DENTISTRY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:DONNA
Authorized Official - Middle Name:
Authorized Official - Last Name:PHILLIPS
Authorized Official - Suffix:
Authorized Official - Credentials:RDH
Authorized Official - Phone:770-674-0226
Mailing Address - Street 1:3921 JOHNS CREEK CT
Mailing Address - Street 2:SUITE A
Mailing Address - City:SUWANEE
Mailing Address - State:GA
Mailing Address - Zip Code:30024-1219
Mailing Address - Country:US
Mailing Address - Phone:770-674-0226
Mailing Address - Fax:770-807-1671
Practice Address - Street 1:3921 JOHNS CREEK CT
Practice Address - Street 2:SUITE A
Practice Address - City:SUWANEE
Practice Address - State:GA
Practice Address - Zip Code:30024-1219
Practice Address - Country:US
Practice Address - Phone:770-674-0226
Practice Address - Fax:770-807-1671
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-04-23
Last Update Date:2016-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN012851223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty