Provider Demographics
NPI:1497977094
Name:LIFETIME DENTAL CARE OF IN, PC
Entity Type:Organization
Organization Name:LIFETIME DENTAL CARE OF IN, PC
Other - Org Name:CLARKSVILLE 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 1:1516 SYNCH LANE
Mailing Address - Street 2:SUITE C
Mailing Address - City:CLARKSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47129
Mailing Address - Country:US
Mailing Address - Phone:812-280-1001
Mailing Address - Fax:812-280-1002
Practice Address - Street 1:1516 SYNCH LANE
Practice Address - Street 2:SUITE C
Practice Address - City:CLARKSVILLE
Practice Address - State:IN
Practice Address - Zip Code:47129
Practice Address - Country:US
Practice Address - Phone:812-280-1001
Practice Address - Fax:812-280-1002
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-03
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty