Provider Demographics
NPI:1497906705
Name:LIFETIME DENTAL, INC
Entity Type:Organization
Organization Name:LIFETIME DENTAL, INC
Other - Org Name:TAVARES DENTAL EXCELLENCE, LLC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:OWNER/DENTIST
Authorized Official - Prefix:MR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:WILLIAM
Authorized Official - Last Name:REINERTSEN
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:352-253-6400
Mailing Address - Street 1:215 E BURLEIGH BLVD
Mailing Address - Street 2:
Mailing Address - City:TAVARES
Mailing Address - State:FL
Mailing Address - Zip Code:32778-2403
Mailing Address - Country:US
Mailing Address - Phone:352-253-6400
Mailing Address - Fax:352-253-6401
Practice Address - Street 1:215 E BURLEIGH BLVD
Practice Address - Street 2:
Practice Address - City:TAVARES
Practice Address - State:FL
Practice Address - Zip Code:32778-2403
Practice Address - Country:US
Practice Address - Phone:352-253-6400
Practice Address - Fax:352-253-6401
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-06
Last Update Date:2018-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN82451223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty