MEDICARE: LIFETIME DENTAL CARE OF INDIANA, 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	:	1568684934
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LIFETIME DENTAL CARE OF INDIANA, PC

Provider Business Mailing Address
First Line	:	8923 SOUTH MERIDIAN STREET
Second Line	:	SUITE B
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46217
Country	:	US
Telephone Number	:	317-887-4800
Fax Number	:	317-887-4801

Provider Business Practice Location Address
First Line	:	8923 SOUTH MERIDIAN STREET
Second Line	:	SUITE B
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46217
Country	:	US
Telephone Number	:	317-887-4800
Fax Number	:	317-887-4801

Authorized Official
Title or Position	:	INS COOD
Name	:	AMY KROEGER
Credential	:
Telephone Number	:	217-540-5100

Provider Enumeration Date	:	05/03/2007
Last Update Date	:	08/22/2020

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