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General NPI Number Information
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NPI Number | 1013179746
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Entity Type | Organization
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Legal Business Name | WIGHTMAN FAMILY DENTAL
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Dates
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Enumeration Date | 06/25/2008
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Last Update Date | 06/25/2008
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Provider Practice Location Address
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Address Line | 2212 PARIS RD
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City | CHALMETTE
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State | LA
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Zip | 70043-5025
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Country | US
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Telephone | 504-272-0870
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Fax | 504-302-9054
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Provider Business Mailing Address
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Address Line | 2212 PARIS RD
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City | CHALMETTE
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State | LA
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Zip | 70043-5025
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Country | US
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Telephone | 504-272-0870
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Fax | 504-302-9054
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Authorized Official
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Title or Position | DENTIST/OWNER
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Name | DR. MARK JOSEPH WIGHTMAN
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Credential | DDS
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Telephone | 504-272-0870
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 5746
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License Number State | LA
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Taxonomy #2
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | 5747
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License Number State | LA
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