Provider Demographics
NPI:1619739679
Name:LIFETIME DENTAL CARE OF MICHIGAN, PC
Entity Type:Organization
Organization Name:LIFETIME DENTAL CARE OF MICHIGAN, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:CEMYIRA
Authorized Official - Middle Name:
Authorized Official - Last Name:MCDOUGAL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:217-764-8609
Mailing Address - Street 1:8110 COOLEY DR
Mailing Address - Street 2:
Mailing Address - City:PORTAGE
Mailing Address - State:MI
Mailing Address - Zip Code:49024-4046
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8110 COOLEY DR
Practice Address - Street 2:
Practice Address - City:PORTAGE
Practice Address - State:MI
Practice Address - Zip Code:49024-4046
Practice Address - Country:US
Practice Address - Phone:269-382-3125
Practice Address - Fax:269-382-3125
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LIFETIME DENTAL CARE OF MICHIGAN, PC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2024-01-25
Last Update Date:2024-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty