MEDICARE: LIFETIME DENTAL CARE PLLC

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	261QD0000X	Dental Clinic/Center

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	2901018159	OTHER	MI	DENTAL LICENSE NUMBER
2	2901019794	OTHER	MI	DENTAL LICENSE NUMBER

General Provider Information

NPI Number	:	1225642242
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LIFETIME DENTAL CARE PLLC

Provider Business Mailing Address
First Line	:	2528 SPRING ARBOR RD
Second Line	:
City	:	JACKSON
State	:	MI
Zip	:	49203-3602
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2528 SPRING ARBOR RD
Second Line	:
City	:	JACKSON
State	:	MI
Zip	:	49203-3602
Country	:	US
Telephone Number	:	517-787-9171
Fax Number	:

Authorized Official
Title or Position	:	MEMBER
Name	:	DR. JAMES CHEN
Credential	:	DDS
Telephone Number	:	517-787-9171

Provider Enumeration Date	:	09/08/2020
Last Update Date	:	09/08/2020

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