Provider Demographics
NPI:1013179746
Name:WIGHTMAN FAMILY DENTAL
Entity Type:Organization
Organization Name:WIGHTMAN FAMILY DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:JOSEPH
Authorized Official - Last Name:WIGHTMAN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:504-272-0870
Mailing Address - Street 1:2212 PARIS RD
Mailing Address - Street 2:
Mailing Address - City:CHALMETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70043-5025
Mailing Address - Country:US
Mailing Address - Phone:504-272-0870
Mailing Address - Fax:504-302-9054
Practice Address - Street 1:2212 PARIS RD
Practice Address - Street 2:
Practice Address - City:CHALMETTE
Practice Address - State:LA
Practice Address - Zip Code:70043-5025
Practice Address - Country:US
Practice Address - Phone:504-272-0870
Practice Address - Fax:504-302-9054
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-25
Last Update Date:2008-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA5746122300000X
LA57471223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
No122300000XDental ProvidersDentistGroup - Single Specialty