Provider Demographics
NPI:1235242801
Name:LIGHTHEART, KURTIS GLEN (DMD)
Entity Type:Individual
Prefix:DR
First Name:KURTIS
Middle Name:GLEN
Last Name:LIGHTHEART
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12704 TIERRA LILY CT
Mailing Address - Street 2:
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79938-5372
Mailing Address - Country:US
Mailing Address - Phone:580-458-1217
Mailing Address - Fax:
Practice Address - Street 1:5005 N. PIEDRAS ST.
Practice Address - Street 2:DENTAC
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79920-5001
Practice Address - Country:US
Practice Address - Phone:915-742-5935
Practice Address - Fax:915-742-5174
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-16
Last Update Date:2011-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY8396122300000X
TX263561223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics
No122300000XDental ProvidersDentist