| NPI | 1396012936 |
|---|---|
| Doing Business As | LIFETIME DENTISTRY AT SHORT PUMP |
| Entity Type | Organization |
| Authorized Contact | ALL CREDENTIALING Credentialing Coordinator 217-540-2100 |
| Organization Subpart ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: VA 0401413582) |
| Additional Taxonomies | 122300000X Dentist (Licence: VA 0401412223) |
| 1223G0001X Dentist, General Practice | |
| Enumeration Date | 2011-11-28 |
| Last Update Date | 2022-10-28 |