Healthcare Provider Details

I. General information

NPI: 1376756635
Provider Name (Legal Business Name): LIFETIME DENTAL CARE OF ILLINOIS, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/07/2007
Last Update Date: 05/21/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1490 NORTH GREENMOUNT ROAD SUITE A
OFALLON IL
62269
US

IV. Provider business mailing address

1490 NORTH GREENMOUNT ROAD SUITE A
OFALLON IL
62269
US

V. Phone/Fax

Practice location:
  • Phone: 618-622-9720
  • Fax: 618-622-1700
Mailing address:
  • Phone: 618-622-9720
  • Fax: 618-622-1700

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State

VIII. Authorized Official

Name: AMY KROEGER
Title or Position: INS COOD
Credential:
Phone: 217-540-5100