Provider Demographics
NPI:1578785036
Name:LIFETIME DENTAL CARE OF INDIANA, PC
Entity Type:Organization
Organization Name:LIFETIME DENTAL CARE OF INDIANA, PC
Other - Org Name:LANDMARK FAMILY DENTAL CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING
Authorized Official - Prefix:
Authorized Official - First Name:ALL
Authorized Official - Middle Name:
Authorized Official - Last Name:CREDENTIALING
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:217-540-2100
Mailing Address - Street 1:1320 W BLOOMFIELD RD
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47403-2001
Mailing Address - Country:US
Mailing Address - Phone:812-339-7743
Mailing Address - Fax:812-339-7383
Practice Address - Street 1:1320 W BLOOMFIELD RD
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47403-2001
Practice Address - Country:US
Practice Address - Phone:812-339-7743
Practice Address - Fax:812-339-7383
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-03
Last Update Date:2022-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty