Organization
LIGHTHOUSE DENTAL LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
DR. JACK E FERGUSON DDS (CO OWNER DENTIST)
(816) 356-2476
Entity
Organization
Contact information
Practice address
10803A E 350 HWY, RAYTOWN, MO 64138
(816) 356-2476
(816) 353-1430
Mailing address
10803A E 350 HWY, RAYTOWN, MO 64138
(816) 356-2476
(816) 353-1430
Taxonomy
Speciality
Code
Description
License number
State
1223G0001X
General Practice Dentistry
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
09718037
BCBS
MO
01
—
33345021
BCBS
MO
Enumeration date
12/05/2006
Last updated
08/22/2020
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