Provider Demographics
NPI:1023678133
Name:LIGHT, JONATHAN
Entity type:Individual
Prefix:
First Name:JONATHAN
Middle Name:
Last Name:LIGHT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:JON
Other - Middle Name:
Other - Last Name:LIGHT
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DMD
Mailing Address - Street 1:2904 BITTERROOT DR
Mailing Address - Street 2:
Mailing Address - City:BILLINGS
Mailing Address - State:MT
Mailing Address - Zip Code:59105-5511
Mailing Address - Country:US
Mailing Address - Phone:801-879-3178
Mailing Address - Fax:
Practice Address - Street 1:3000 HOSPITAL WAY
Practice Address - Street 2:
Practice Address - City:WHITEFISH
Practice Address - State:MT
Practice Address - Zip Code:59937-7838
Practice Address - Country:US
Practice Address - Phone:406-862-3839
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-20
Last Update Date:2019-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTDEN-DEN-LIC-173771223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice