Provider Demographics
NPI:1699987545
Name:LIFETIME DENTAL CARE OF INDIANA, PC
Entity type:Organization
Organization Name:LIFETIME DENTAL CARE OF INDIANA, PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:INS COOD
Authorized Official - Prefix:
Authorized Official - First Name:AMY
Authorized Official - Middle Name:
Authorized Official - Last Name:KROEGER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:217-540-5100
Mailing Address - Street 1:11681 BROOKS SCHOOL ROAD
Mailing Address - Street 2:SUITE 2
Mailing Address - City:FISHERS
Mailing Address - State:IN
Mailing Address - Zip Code:46038
Mailing Address - Country:US
Mailing Address - Phone:317-913-9694
Mailing Address - Fax:317-915-8683
Practice Address - Street 1:11681 BROOKS SCHOOL ROAD
Practice Address - Street 2:SUITE 2
Practice Address - City:FISHERS
Practice Address - State:IN
Practice Address - Zip Code:46038
Practice Address - Country:US
Practice Address - Phone:317-913-9694
Practice Address - Fax:317-915-8683
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-04
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty