Provider Demographics
NPI:1417350331
Name:LIGHTHALL FAMILY DENTISTRY OF GILBERT PLC
Entity Type:Organization
Organization Name:LIGHTHALL FAMILY DENTISTRY OF GILBERT PLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:SKYLAR
Authorized Official - Middle Name:ALAN
Authorized Official - Last Name:LIGHTHALL
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:480-807-6453
Mailing Address - Street 1:3509 S MERCY RD
Mailing Address - Street 2:SUITE 107
Mailing Address - City:GILBERT
Mailing Address - State:AZ
Mailing Address - Zip Code:85297-0442
Mailing Address - Country:US
Mailing Address - Phone:480-807-6453
Mailing Address - Fax:480-814-9005
Practice Address - Street 1:3509 S MERCY RD
Practice Address - Street 2:SUITE 107
Practice Address - City:GILBERT
Practice Address - State:AZ
Practice Address - Zip Code:85297-0442
Practice Address - Country:US
Practice Address - Phone:480-807-6453
Practice Address - Fax:480-814-9005
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-10-06
Last Update Date:2014-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZD0008620122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ908239Medicaid