MEDICARE: LIFETIME DENTAL CARE OF MICHIGAN, PC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry

General Provider Information

NPI Number	:	1316305063
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LIFETIME DENTAL CARE OF MICHIGAN, PC

Provider Business Mailing Address
First Line	:	6127 RAWSONVILLE RD
Second Line	:	SUITE 118
City	:	BELLEVILLE
State	:	MI
Zip	:	48111-2546
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	6127 RAWSONVILLE RD
Second Line	:	SUITE 118
City	:	BELLEVILLE
State	:	MI
Zip	:	48111-2546
Country	:	US
Telephone Number	:	734-720-9827
Fax Number	:

Authorized Official
Title or Position	:	CREDENTIALING TEAM LEAD
Name	:	KENDRA WALKER
Credential	:
Telephone Number	:	217-540-8312

Provider Enumeration Date	:	02/09/2016
Last Update Date	:	02/29/2016

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