Healthcare Provider Details

I. General information

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

II. Dates (important events)

Enumeration Date: 05/23/2007
Last Update Date: 08/13/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11721 WOODMORE RD 170
MITCHELLVILLE MD
20721-4117
US

IV. Provider business mailing address

1200 NETWORK CENTRE DRIVE SUITE #2
EFFINGHAM IL
62401
US

V. Phone/Fax

Practice location:
  • Phone: 301-218-4110
  • Fax: 310-218-4120
Mailing address:
  • Phone: 217-540-8946
  • Fax: 217-540-8946

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number07158
License Number StateDC
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number10283
License Number StateDC

VIII. Authorized Official

Name: BRITTANY NICHELLE HOWARD
Title or Position: CREDENTIALING AFFILIATION COORDINAT
Credential:
Phone: 217-540-8946