Provider Demographics
NPI:1861410763
Name:LIGHTSHIP DENTAL INC
Entity type:Organization
Organization Name:LIGHTSHIP DENTAL INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:R
Authorized Official - Last Name:LAKE
Authorized Official - Suffix:JR
Authorized Official - Credentials:DDS
Authorized Official - Phone:508-428-4929
Mailing Address - Street 1:1322 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:OSTERVILLE
Mailing Address - State:MA
Mailing Address - Zip Code:02655-1542
Mailing Address - Country:US
Mailing Address - Phone:508-428-4929
Mailing Address - Fax:508-420-2943
Practice Address - Street 1:1322 MAIN ST
Practice Address - Street 2:
Practice Address - City:OSTERVILLE
Practice Address - State:MA
Practice Address - Zip Code:02655-1542
Practice Address - Country:US
Practice Address - Phone:508-428-4929
Practice Address - Fax:508-420-2943
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-18
Last Update Date:2015-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA145411223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA7409150001Medicare NSC