Provider Demographics
NPI:1265959837
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:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:TABATHA
Authorized Official - Middle Name:FORREST
Authorized Official - Last Name:LEMKE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:217-540-8946
Mailing Address - Street 1:1200 NETWORK CENTER DR
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 1:13919 BALTIMORE AVE
Practice Address - Street 2:
Practice Address - City:LAUREL
Practice Address - State:MD
Practice Address - Zip Code:20707-5044
Practice Address - Country:US
Practice Address - Phone:301-498-6511
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DENTAL PROFESSIONALS OF MARYLAND, GERALD AWADZI, P.C.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2017-08-24
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty