Healthcare Provider Details

I. General information

NPI: 1659796944
Provider Name (Legal Business Name): LIFETIME DENTAL CARE SC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/24/2014
Last Update Date: 02/24/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

822 S HASTINGS WAY
EAU CLAIRE WI
54701-3426
US

IV. Provider business mailing address

822 S HASTINGS WAY
EAU CLAIRE WI
54701-3426
US

V. Phone/Fax

Practice location:
  • Phone: 715-552-1000
  • Fax: 715-552-2772
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number5001709-15
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code332BC3200X
TaxonomyCustomized Equipment (DME)
License Number
License Number State

VIII. Authorized Official

Name: ANTHONY R BUTCHERT
Title or Position: OWNER
Credential: DDS
Phone: 715-552-1000