Provider Demographics
NPI:1801018197
Name:LIFETIME DENTAL CARE OF ILLINOIS, PC
Entity Type:Organization
Organization Name:LIFETIME DENTAL CARE OF ILLINOIS, PC
Other - Org Name:DEKALB DENTAL GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:INS COOD
Authorized Official - Prefix:
Authorized Official - First Name:AMY
Authorized Official - Middle Name:
Authorized Official - Last Name:KROEGER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:217-540-5100
Mailing Address - Street 1:2707 SYCAMORE ROAD
Mailing Address - Street 2:
Mailing Address - City:DEKALB
Mailing Address - State:IL
Mailing Address - Zip Code:60115
Mailing Address - Country:US
Mailing Address - Phone:815-756-4430
Mailing Address - Fax:815-756-4350
Practice Address - Street 1:2707 SYCAMORE ROAD
Practice Address - Street 2:
Practice Address - City:DEKALB
Practice Address - State:IL
Practice Address - Zip Code:60115
Practice Address - Country:US
Practice Address - Phone:815-756-4430
Practice Address - Fax:815-756-4350
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-03
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty