Provider Demographics
NPI:1710045224
Name:LIGHTHOUSE DENTAL LLC
Entity type:Organization
Organization Name:LIGHTHOUSE DENTAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO OWNER DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JACK
Authorized Official - Middle Name:E
Authorized Official - Last Name:FERGUSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:816-356-2476
Mailing Address - Street 1:10803A E 350 HWY
Mailing Address - Street 2:
Mailing Address - City:RAYTOWN
Mailing Address - State:MO
Mailing Address - Zip Code:64138
Mailing Address - Country:US
Mailing Address - Phone:816-356-2476
Mailing Address - Fax:816-353-1430
Practice Address - Street 1:10803A E 350 HWY
Practice Address - Street 2:
Practice Address - City:RAYTOWN
Practice Address - State:MO
Practice Address - Zip Code:64138
Practice Address - Country:US
Practice Address - Phone:816-356-2476
Practice Address - Fax:816-353-1430
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-05
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO09718037OtherBCBS
MO33345021OtherBCBS