Healthcare Provider Details

I. General information

NPI: 1487614483
Provider Name (Legal Business Name): JOHN PHILIP LIGHTFOOT D.M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 03/24/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4275 LOMAC ST
MONTGOMERY AL
36106-2915
US

IV. Provider business mailing address

4275 LOMAC ST
MONTGOMERY AL
36106-2915
US

V. Phone/Fax

Practice location:
  • Phone: 334-271-0440
  • Fax: 334-409-0815
Mailing address:
  • Phone: 334-271-0440
  • Fax: 334-409-0815

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number3520
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: