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General NPI Number Information
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NPI Number | 1174631287
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Entity Type | Organization
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Legal Business Name | LIGHTHOUSE DENTAL GROUP
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Dates
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Enumeration Date | 08/28/2006
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Last Update Date | 01/12/2010
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Provider Practice Location Address
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Address Line | 1177 N EAGLE RD
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City | EAGLE
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State | ID
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Zip | 83616
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Country | US
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Telephone | 208-939-3010
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Fax | 208-939-3027
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Provider Business Mailing Address
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Address Line | 1177 N EAGLE RD
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City | EAGLE
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State | ID
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Zip | 83616
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Country | US
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Telephone | 208-939-3010
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Fax | 208-939-3027
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Authorized Official
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Title or Position | PARTNER/DENTIST
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Name | MR. MICHAEL LYNN HIGGINSON
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Credential | DDS
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Telephone | 208-939-3010
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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 | DRUG ID #BH6399857
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License Number State | ID
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Taxonomy #2
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | D3878
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License Number State | ID
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Taxonomy #3
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | DRUG ID #BJ9304623
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License Number State | ID
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Taxonomy #4
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | D3380
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License Number State | ID
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