MEDICARE: LIFETIME DENTAL CARE OF MARYLAND, BADGER, P.C.

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	10283	DC
2	122300000X	Dentist	07158	DC

General Provider Information

NPI Number	:	1972713352
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LIFETIME DENTAL CARE OF MARYLAND, BADGER, P.C.

Provider Business Mailing Address
First Line	:	1200 NETWORK CENTRE DRIVE
Second Line	:	SUITE #2
City	:	EFFINGHAM
State	:	IL
Zip	:	62401
Country	:	US
Telephone Number	:	217-540-8946
Fax Number	:	217-540-8946

Provider Business Practice Location Address
First Line	:	11721 WOODMORE RD
Second Line	:	170
City	:	MITCHELLVILLE
State	:	MD
Zip	:	20721-4117
Country	:	US
Telephone Number	:	301-218-4110
Fax Number	:	310-218-4120

Authorized Official
Title or Position	:	CREDENTIALING AFFILIATION COORDINAT
Name	:	BRITTANY NICHELLE HOWARD
Credential	:
Telephone Number	:	217-540-8946

Provider Enumeration Date	:	05/23/2007
Last Update Date	:	08/13/2019

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