Provider Demographics
NPI:1659796944
Name:LIFETIME DENTAL CARE SC
Entity Type:Organization
Organization Name:LIFETIME DENTAL CARE SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ANTHONY
Authorized Official - Middle Name:R
Authorized Official - Last Name:BUTCHERT
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:715-552-1000
Mailing Address - Street 1:822 S HASTINGS WAY
Mailing Address - Street 2:
Mailing Address - City:EAU CLAIRE
Mailing Address - State:WI
Mailing Address - Zip Code:54701-3426
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:822 S HASTINGS WAY
Practice Address - Street 2:
Practice Address - City:EAU CLAIRE
Practice Address - State:WI
Practice Address - Zip Code:54701-3426
Practice Address - Country:US
Practice Address - Phone:715-552-1000
Practice Address - Fax:715-552-2772
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-02-24
Last Update Date:2014-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5001709-15122300000X
332BC3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
No332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized EquipmentGroup - Single Specialty