Provider Demographics
NPI:1902028178
Name:LIFETIME DENTAL CARE OF ILLINOIS, PC
Entity Type:Organization
Organization Name:LIFETIME DENTAL CARE OF ILLINOIS, PC
Other - Org Name:DENTAL GROUP OF ROCKFORD
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 1:3065 N PERRYVILLE RD UNIT 125
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61114-8036
Mailing Address - Country:US
Mailing Address - Phone:815-637-2273
Mailing Address - Fax:815-637-2466
Practice Address - Street 1:3065 N PERRYVILLE RD UNIT 125
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61114-8036
Practice Address - Country:US
Practice Address - Phone:815-637-2273
Practice Address - Fax:815-637-2466
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-03
Last Update Date:2010-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty