Provider Demographics
NPI:1962461228
Name:LIGHT, DENNIS JOHN (OD)
Entity Type:Individual
Prefix:DR
First Name:DENNIS
Middle Name:JOHN
Last Name:LIGHT
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4100 W THIRD STREET
Mailing Address - Street 2:DAYTON VAMC EYE CLINIC 112E
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45428
Mailing Address - Country:US
Mailing Address - Phone:937-268-6511
Mailing Address - Fax:
Practice Address - Street 1:4100 W THIRD STREET
Practice Address - Street 2:DAYTON VAMC EYE CLINIC 112E
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45428
Practice Address - Country:US
Practice Address - Phone:937-268-6511
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-23
Last Update Date:2013-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH4366152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0936796Medicaid
OH0746822Medicare ID - Type Unspecified
OHU44202Medicare UPIN