Provider Demographics
NPI:1639340128
Name:LIFETIME DENTAL, PA
Entity Type:Organization
Organization Name:LIFETIME DENTAL, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST/ PRESIDENT
Authorized Official - Prefix:MS
Authorized Official - First Name:SAMANEH
Authorized Official - Middle Name:MARYAM
Authorized Official - Last Name:DAFTARIAN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:281-213-8666
Mailing Address - Street 1:10750 BARKER CYPRESS RD STE 111
Mailing Address - Street 2:
Mailing Address - City:CYPRESS
Mailing Address - State:TX
Mailing Address - Zip Code:77433-2282
Mailing Address - Country:US
Mailing Address - Phone:281-213-8666
Mailing Address - Fax:281-256-2819
Practice Address - Street 1:10750 BARKER CYPRESS RD STE 111
Practice Address - Street 2:
Practice Address - City:CYPRESS
Practice Address - State:TX
Practice Address - Zip Code:77433-2282
Practice Address - Country:US
Practice Address - Phone:281-213-8666
Practice Address - Fax:281-256-2819
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-12
Last Update Date:2011-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX178127001Medicaid