Healthcare Provider Details

I. General information

NPI: 1881982122
Provider Name (Legal Business Name): LIGHTHOUSE FAMILY DENTISTRY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/20/2011
Last Update Date: 07/20/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3159 HIGHWAY 64 STE 100
EADS TN
38028-3322
US

IV. Provider business mailing address

3159 HIGHWAY 64 STE 100
EADS TN
38028-3322
US

V. Phone/Fax

Practice location:
  • Phone: 901-465-2382
  • Fax:
Mailing address:
  • Phone: 901-465-2382
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number8582
License Number StateTN

VIII. Authorized Official

Name: DR. MARILYN LIZ PHILLIPS
Title or Position: OWNER
Credential: D.D.S
Phone: 901-465-2382