Provider Demographics
NPI:1689152282
Name:EASTLIGHT DENTAL, L.L.C.
Entity Type:Organization
Organization Name:EASTLIGHT DENTAL, L.L.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:EDMUND
Authorized Official - Middle Name:
Authorized Official - Last Name:THOMAS
Authorized Official - Suffix:JR
Authorized Official - Credentials:DDS
Authorized Official - Phone:716-949-2183
Mailing Address - Street 1:2536 ROCKBRIDGE RD STE 103
Mailing Address - Street 2:
Mailing Address - City:STONE MOUNTAIN
Mailing Address - State:GA
Mailing Address - Zip Code:30087-3636
Mailing Address - Country:US
Mailing Address - Phone:678-395-5913
Mailing Address - Fax:678-395-5678
Practice Address - Street 1:2536 ROCKBRIDGE RD STE 103
Practice Address - Street 2:
Practice Address - City:STONE MOUNTAIN
Practice Address - State:GA
Practice Address - Zip Code:30087-3636
Practice Address - Country:US
Practice Address - Phone:678-395-5913
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-08-06
Last Update Date:2018-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental