Provider Demographics
NPI:1578011623
Name:JOHN D. LIGHT, DMD, PA
Entity Type:Organization
Organization Name:JOHN D. LIGHT, DMD, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:D
Authorized Official - Last Name:LIGHT
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:561-965-9345
Mailing Address - Street 1:3015 S CONGRESS AVE
Mailing Address - Street 2:SUITE #3
Mailing Address - City:PALM SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:33461-2111
Mailing Address - Country:US
Mailing Address - Phone:561-965-9345
Mailing Address - Fax:561-965-1774
Practice Address - Street 1:3015 S CONGRESS AVE
Practice Address - Street 2:SUITE #3
Practice Address - City:PALM SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:33461-2111
Practice Address - Country:US
Practice Address - Phone:561-965-9345
Practice Address - Fax:561-965-1774
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-09-19
Last Update Date:2016-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN84181223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty