1003088873 NPI number — BRIGHT SMILES, LLC

Table of content: (NPI 1003088873)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1003088873 NPI number — BRIGHT SMILES, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BRIGHT SMILES, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1003088873
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/01/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
907 PAVILION CT
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MCDONOUGH
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30253-6665
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
678-583-8536
Provider Business Mailing Address Fax Number:
678-583-8657

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
907 PAVILION CT
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MCDONOUGH
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30253-6665
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
678-583-8536
Provider Business Practice Location Address Fax Number:
678-583-8657
Provider Enumeration Date:
04/01/2008

Additional Information

Authorized Official

Authorized Official Last Name:
THOMPSON
Authorized Official First Name:
SHUNDA
Authorized Official Middle Name:
L
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
678-583-8536

Provider Taxonomy Codes

  • Taxonomy code: 1223X0400X , with the licence number:  DN012649 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1235292897 , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 9181762 . This is a "GA PROVIDER NUMBER" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 1585058 . This is a "UNITED CONCORDIA" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 9199332 . This is a "GA PROVIDER ID" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 100486 . This is a "GA PROVIDER ID" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 101869 . This is a "GA PROVIDER ID" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".




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