Provider Demographics
NPI:1558975177
Name:LIFETIME DENTAL CARE OF WISCONSIN, S.C.
Entity Type:Organization
Organization Name:LIFETIME DENTAL CARE OF WISCONSIN, S.C.
Other - Org Name:JEFFREY L. SORENSEN, DDS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:COURTNEY
Authorized Official - Middle Name:
Authorized Official - Last Name:MONTEITH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:217-540-8306
Mailing Address - Street 1:24418 75TH ST
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:WI
Mailing Address - Zip Code:53168-9703
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:24418 75TH ST
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:WI
Practice Address - Zip Code:53168-9703
Practice Address - Country:US
Practice Address - Phone:262-843-2004
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:HEARTLAND DENTAL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2020-09-01
Last Update Date:2022-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty