Provider Demographics
NPI:1659730380
Name:LIFETIME DENTAL CARE OF MARYLAND, BADGER, P.C.
Entity Type:Organization
Organization Name:LIFETIME DENTAL CARE OF MARYLAND, BADGER, P.C.
Other - Org Name:DENTAL PROFESSIONALS OF MARYLAND, GERALD AWADZI, PC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:CREDENTIALING AFFILIATION COORDINAT
Authorized Official - Prefix:
Authorized Official - First Name:BRITTANY
Authorized Official - Middle Name:NICHELLE
Authorized Official - Last Name:HOWARD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:217-540-8946
Mailing Address - Street 1:1200 NETWORK CENTRE DRIVE
Mailing Address - Street 2:SUITE #2
Mailing Address - City:EFFINGHAM
Mailing Address - State:IL
Mailing Address - Zip Code:62401
Mailing Address - Country:US
Mailing Address - Phone:217-540-8946
Mailing Address - Fax:217-540-8946
Practice Address - Street 1:6400 RIDGE RD # H
Practice Address - Street 2:
Practice Address - City:SYKESVILLE
Practice Address - State:MD
Practice Address - Zip Code:21784-6248
Practice Address - Country:US
Practice Address - Phone:410-702-5040
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DENTAL PROFESSIONALS OF MARYLAND, GERALD AWADZI, PC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-02-23
Last Update Date:2019-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty