Provider Demographics
NPI:1174631287
Name:LIGHTHOUSE DENTAL GROUP
Entity Type:Organization
Organization Name:LIGHTHOUSE DENTAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER/DENTIST
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:HIGGINSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:208-939-3010
Mailing Address - Street 1:1177 N EAGLE RD
Mailing Address - Street 2:
Mailing Address - City:EAGLE
Mailing Address - State:ID
Mailing Address - Zip Code:83616
Mailing Address - Country:US
Mailing Address - Phone:208-939-3010
Mailing Address - Fax:208-939-3027
Practice Address - Street 1:1177 N EAGLE RD
Practice Address - Street 2:
Practice Address - City:EAGLE
Practice Address - State:ID
Practice Address - Zip Code:83616
Practice Address - Country:US
Practice Address - Phone:208-939-3010
Practice Address - Fax:208-939-3027
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-28
Last Update Date:2010-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD3380122300000X
IDDRUG ID #BH6399857122300000X
IDD3878122300000X
IDDRUG ID #BJ9304623122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
450530374Medicare UPIN