Provider Demographics
NPI:1902339062
Name:LIFETIME DENTAL CARE OF MARYLAND BADGER, P.C.
Entity type:Organization
Organization Name:LIFETIME DENTAL CARE OF MARYLAND BADGER, P.C.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING AFFILIATION COORDINAT
Authorized Official - Prefix:
Authorized Official - First Name:BRITTANY
Authorized Official - Middle Name:NICHELLE
Authorized Official - Last Name:HOWARD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:217-590-8946
Mailing Address - Street 1:1200 NETWORK CENTRE DRIVE
Mailing Address - Street 2:SUITE #2
Mailing Address - City:EFFINGHAM
Mailing Address - State:IL
Mailing Address - Zip Code:62401
Mailing Address - Country:US
Mailing Address - Phone:217-540-8946
Mailing Address - Fax:217-540-8946
Practice Address - Street 1:4959 WESTVIEW DR
Practice Address - Street 2:SUITE F
Practice Address - City:FREDERICK
Practice Address - State:MD
Practice Address - Zip Code:21703-7369
Practice Address - Country:US
Practice Address - Phone:301-363-1211
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DENTAL PROFESSIONALS OF MARYLAND, GERALD AWADZI, PC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2017-04-06
Last Update Date:2019-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty