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 |