Provider Demographics
NPI:1750435558
Name:LIFETIME DENTAL HEALTH, PA
Entity type:Organization
Organization Name:LIFETIME DENTAL HEALTH, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:SAMUEL
Authorized Official - Last Name:GREEN
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:207-892-8548
Mailing Address - Street 1:731 ROOSEVELT TRL
Mailing Address - Street 2:
Mailing Address - City:WINDHAM
Mailing Address - State:ME
Mailing Address - Zip Code:04062-5269
Mailing Address - Country:US
Mailing Address - Phone:207-892-8548
Mailing Address - Fax:207-892-6651
Practice Address - Street 1:731 ROOSEVELT TRL
Practice Address - Street 2:
Practice Address - City:WINDHAM
Practice Address - State:ME
Practice Address - Zip Code:04062-5269
Practice Address - Country:US
Practice Address - Phone:207-892-8548
Practice Address - Fax:207-892-6651
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-22
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME25081223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME1861477606OtherNPI-PERSONAL NUMBER