Provider Demographics
NPI:1336361740
Name:LIFETIME DENTAL CARE OF INDIANA, PC
Entity Type:Organization
Organization Name:LIFETIME DENTAL CARE OF INDIANA, PC
Other - Org Name:DENTAL DESIGN OF FORT WAYNE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:INS COOD
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:
Authorized Official - Last Name:HOELSCHER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:217-540-5100
Mailing Address - Street 1:2828 E STATE BLVD
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46805-4761
Mailing Address - Country:US
Mailing Address - Phone:260-482-6689
Mailing Address - Fax:260-482-6948
Practice Address - Street 1:2828 E STATE BLVD
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46805-4761
Practice Address - Country:US
Practice Address - Phone:260-482-6689
Practice Address - Fax:260-482-6948
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LIFETIME DENTAL CARE OF INDIANA, PC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-05-03
Last Update Date:2014-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty