Provider Demographics
NPI:1841521879
Name:LIFETIME AND COSMETIC DENTISTRY
Entity type:Organization
Organization Name:LIFETIME AND COSMETIC DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SONYA
Authorized Official - Middle Name:
Authorized Official - Last Name:AUSTIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:817-750-5433
Mailing Address - Street 1:5040 N TARRANT PKWY
Mailing Address - Street 2:SUITE 118
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76244-5389
Mailing Address - Country:US
Mailing Address - Phone:817-750-5433
Mailing Address - Fax:817-750-5431
Practice Address - Street 1:5040 N TARRANT PKWY
Practice Address - Street 2:SUITE 118
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76244-5389
Practice Address - Country:US
Practice Address - Phone:817-750-5433
Practice Address - Fax:817-750-5431
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-01-14
Last Update Date:2010-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX215611223G0001X
TX213811223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX21561Other1223G0001X-DENTIST-GENERAL PRACTICE
TX21381Other1223G0001X-DENTIST-GENERAL PRACTISE