Basic Information
| Provider Information | |||||||||
| NPI: | 1235242801 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LIGHTHEART | ||||||||
| FirstName: | KURTIS | ||||||||
| MiddleName: | GLEN | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | DMD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 12704 TIERRA LILY CT | ||||||||
| Address2: | |||||||||
| City: | EL PASO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 799385372 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5804581217 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 5005 N. PIEDRAS ST. | ||||||||
| Address2: | DENTAC | ||||||||
| City: | EL PASO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 799205001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9157425935 | ||||||||
| FaxNumber: | 9157425174 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/16/2006 | ||||||||
| LastUpdateDate: | 09/16/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X | 8396 | KY | N | Dental Providers | Dentist | 1223X0400X | 26356 | TX | Y | Dental Providers | Dentist | Orthodontics and Dentofacial Orthopedics |
No ID Information.