Provider Demographics
NPI:1669880845
Name:LIFETIME DENTAL PARTNERS, PLLC
Entity type:Organization
Organization Name:LIFETIME DENTAL PARTNERS, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ROBERTA
Authorized Official - Middle Name:LEA
Authorized Official - Last Name:EKMAN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:701-352-2450
Mailing Address - Street 1:927 W 12TH ST
Mailing Address - Street 2:
Mailing Address - City:GRAFTON
Mailing Address - State:ND
Mailing Address - Zip Code:58237-2121
Mailing Address - Country:US
Mailing Address - Phone:701-352-2450
Mailing Address - Fax:701-352-2424
Practice Address - Street 1:321 BRIGGS AVE S
Practice Address - Street 2:SUITE 3
Practice Address - City:PARK RIVER
Practice Address - State:ND
Practice Address - Zip Code:58270
Practice Address - Country:US
Practice Address - Phone:701-284-7777
Practice Address - Fax:701-284-6776
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-07-31
Last Update Date:2024-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND1904261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDentalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND1458306Medicaid