Provider Demographics
NPI:1457337495
Name:LIFETIME FAMILY DENTISTRY LLC
Entity Type:Organization
Organization Name:LIFETIME FAMILY DENTISTRY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:SUZANNE
Authorized Official - Middle Name:M
Authorized Official - Last Name:LOWRY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:864-984-6888
Mailing Address - Street 1:310 OWINGS ST
Mailing Address - Street 2:
Mailing Address - City:LAURENS
Mailing Address - State:SC
Mailing Address - Zip Code:29360-2738
Mailing Address - Country:US
Mailing Address - Phone:864-984-6888
Mailing Address - Fax:864-984-4474
Practice Address - Street 1:310 OWINGS ST
Practice Address - Street 2:
Practice Address - City:LAURENS
Practice Address - State:SC
Practice Address - Zip Code:29360-2738
Practice Address - Country:US
Practice Address - Phone:864-984-6888
Practice Address - Fax:864-984-4474
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-21
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC33801223G0001X
SC40361223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCZA9540Medicaid