Provider Demographics
NPI:1952659153
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:KEY WEST CROSSING DENTAL ASSOCIATES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:TABATHA
Authorized Official - Middle Name:
Authorized Official - Last Name:LEMKE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:217-540-6078
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 1:15020 SHADY GROVE RD
Practice Address - Street 2:
Practice Address - City:ROCKVILLE
Practice Address - State:MD
Practice Address - Zip Code:20850-3364
Practice Address - Country:US
Practice Address - Phone:301-738-2111
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-08-17
Last Update Date:2021-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty