Provider Demographics
NPI:1083282537
Name:TRAVELING LIGHT DENTAL LLC
Entity Type:Organization
Organization Name:TRAVELING LIGHT DENTAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:MR
Authorized Official - First Name:BENJAMIN
Authorized Official - Middle Name:MARK
Authorized Official - Last Name:KACOS
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:318-869-2593
Mailing Address - Street 1:230 CARROLL ST
Mailing Address - Street 2:SUITE 3
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71105
Mailing Address - Country:US
Mailing Address - Phone:318-869-2593
Mailing Address - Fax:318-869-2592
Practice Address - Street 1:230 CARROLL ST
Practice Address - Street 2:SUITE 3
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71105
Practice Address - Country:US
Practice Address - Phone:318-869-2593
Practice Address - Fax:318-869-2592
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-06-11
Last Update Date:2021-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty