Provider Demographics
NPI:1497979918
Name:LIFETIME DENTAL PROFESSIONALS OF NEW HAMPSHIRE, P.C.
Entity Type:Organization
Organization Name:LIFETIME DENTAL PROFESSIONALS OF NEW HAMPSHIRE, P.C.
Other - Org Name:MAIN STREET DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:LORI
Authorized Official - Middle Name:
Authorized Official - Last Name:EDMONDS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:217-540-8468
Mailing Address - Street 1:107 MAIN STREET
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH
Mailing Address - State:NH
Mailing Address - Zip Code:03264
Mailing Address - Country:US
Mailing Address - Phone:603-536-4009
Mailing Address - Fax:603-536-1033
Practice Address - Street 1:107 MAIN STREET
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:NH
Practice Address - Zip Code:03264
Practice Address - Country:US
Practice Address - Phone:603-536-4009
Practice Address - Fax:603-536-1033
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LIFETIME DENTAL PROFESSIONALS OF NEW HAM
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-04-13
Last Update Date:2016-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH1223G0001X
1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH30300441Medicaid