Provider Demographics
NPI:1265064588
Name:LIT DENTAL, P.C.
Entity type:Organization
Organization Name:LIT DENTAL, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PROSTHODONTIST
Authorized Official - Prefix:
Authorized Official - First Name:MIGUEL
Authorized Official - Middle Name:
Authorized Official - Last Name:ORTIZ
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:626-315-2028
Mailing Address - Street 1:109 ANDREW AVE STE 202
Mailing Address - Street 2:
Mailing Address - City:WAYLAND
Mailing Address - State:MA
Mailing Address - Zip Code:01778-3157
Mailing Address - Country:US
Mailing Address - Phone:508-358-2122
Mailing Address - Fax:
Practice Address - Street 1:109 ANDREW AVE STE 202
Practice Address - Street 2:
Practice Address - City:WAYLAND
Practice Address - State:MA
Practice Address - Zip Code:01778-3157
Practice Address - Country:US
Practice Address - Phone:508-358-2122
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-02-05
Last Update Date:2020-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
No122300000XDental ProvidersDentistGroup - Multi-Specialty
No124Q00000XDental ProvidersDental HygienistGroup - Multi-Specialty
No1223P0700XDental ProvidersDentistProsthodonticsGroup - Multi-Specialty
No126800000XDental ProvidersDental AssistantGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MADN1857495OtherLICENSE NUMBER