Provider Demographics
NPI:1942364930
Name:LIFETIME DENTAL CARE OF KY PSC
Entity Type:Organization
Organization Name:LIFETIME DENTAL CARE OF KY PSC
Other - Org Name:ST. MATHEWS DENTAL CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CRED SUPERVISOR
Authorized Official - Prefix:
Authorized Official - First Name:KIM
Authorized Official - Middle Name:A
Authorized Official - Last Name:ZUBER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:217-540-5100
Mailing Address - Street 1:219 BRECKENRIDGE LN
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40207-3858
Mailing Address - Country:US
Mailing Address - Phone:502-897-3424
Mailing Address - Fax:502-894-0342
Practice Address - Street 1:219 BRECKENRIDGE LN
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40207-3858
Practice Address - Country:US
Practice Address - Phone:502-897-3424
Practice Address - Fax:502-894-0342
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LIFETIME DENTAL CARE OF KY PSC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-12-21
Last Update Date:2017-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty