Provider Demographics
NPI:1912617929
Name:THE LIGHT FAMILY DENTAL AND IMPLANT DENTISTRY PLLC
Entity Type:Organization
Organization Name:THE LIGHT FAMILY DENTAL AND IMPLANT DENTISTRY PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DMD
Authorized Official - Prefix:
Authorized Official - First Name:ANDREW
Authorized Official - Middle Name:
Authorized Official - Last Name:AKINDUTIRE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:301-795-5013
Mailing Address - Street 1:8214 FM-78
Mailing Address - Street 2:SUITE 105
Mailing Address - City:CONVERSE
Mailing Address - State:TX
Mailing Address - Zip Code:78109
Mailing Address - Country:US
Mailing Address - Phone:210-920-4963
Mailing Address - Fax:210-783-8656
Practice Address - Street 1:8214 FM-78
Practice Address - Street 2:SUITE 105
Practice Address - City:CONVERSE
Practice Address - State:TX
Practice Address - Zip Code:78109
Practice Address - Country:US
Practice Address - Phone:210-920-4963
Practice Address - Fax:210-783-8656
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-11-30
Last Update Date:2022-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
No261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDentalGroup - Single Specialty