Provider Demographics
NPI:1972892214
Name:LIFETIME FAMILY DENTISTRY OF TWO RIVERS
Entity Type:Organization
Organization Name:LIFETIME FAMILY DENTISTRY OF TWO RIVERS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:
Authorized Official - Last Name:BUCK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:608-220-1168
Mailing Address - Street 1:1509 19TH ST
Mailing Address - Street 2:
Mailing Address - City:TWO RIVERS
Mailing Address - State:WI
Mailing Address - Zip Code:54241-2628
Mailing Address - Country:US
Mailing Address - Phone:920-794-8947
Mailing Address - Fax:920-793-8463
Practice Address - Street 1:1509 19TH ST
Practice Address - Street 2:
Practice Address - City:TWO RIVERS
Practice Address - State:WI
Practice Address - Zip Code:54241-2628
Practice Address - Country:US
Practice Address - Phone:920-794-8947
Practice Address - Fax:920-793-8463
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-04-06
Last Update Date:2011-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI36390151223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty