Provider Demographics
NPI:1871687152
Name:LIGHTMAN, MORDECAI SHALOM (DDS)
Entity Type:Individual
Prefix:
First Name:MORDECAI
Middle Name:SHALOM
Last Name:LIGHTMAN
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5256 COLLEGE GARDENS CT
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92115
Mailing Address - Country:US
Mailing Address - Phone:619-286-6420
Mailing Address - Fax:
Practice Address - Street 1:6244 EL CAJON BLVD
Practice Address - Street 2:#14
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92115
Practice Address - Country:US
Practice Address - Phone:619-583-6791
Practice Address - Fax:619-583-4101
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA254171223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice