Provider Demographics
NPI:1538805346
Name:LIFE BRIDGE DENTAL LLC
Entity type:Organization
Organization Name:LIFE BRIDGE DENTAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR, RCM
Authorized Official - Prefix:MR
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:NEILQ
Authorized Official - Last Name:SULLIVAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:212-686-3686
Mailing Address - Street 1:8 CITY BLVD STE 203
Mailing Address - Street 2:
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37209-2559
Mailing Address - Country:US
Mailing Address - Phone:212-686-3686
Mailing Address - Fax:615-468-0325
Practice Address - Street 1:11564 OLD GEORGETOWN ROAD
Practice Address - Street 2:
Practice Address - City:NORTH BETHESDA
Practice Address - State:MD
Practice Address - Zip Code:20852
Practice Address - Country:US
Practice Address - Phone:212-686-3686
Practice Address - Fax:615-468-0325
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-05-05
Last Update Date:2022-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty