Provider Demographics
NPI:1003213646
Name:BRIGHT SMILE DENTAL CARE
Entity Type:Organization
Organization Name:BRIGHT SMILE DENTAL CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:SUNG
Authorized Official - Middle Name:H
Authorized Official - Last Name:KONG
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:317-845-5100
Mailing Address - Street 1:11530 ALLISONVILLE RD
Mailing Address - Street 2:SUITE 175
Mailing Address - City:FISHERS
Mailing Address - State:IN
Mailing Address - Zip Code:46038-1866
Mailing Address - Country:US
Mailing Address - Phone:317-845-5100
Mailing Address - Fax:317-845-5200
Practice Address - Street 1:11530 ALLISONVILLE RD
Practice Address - Street 2:SUITE 175
Practice Address - City:FISHERS
Practice Address - State:IN
Practice Address - Zip Code:46038-1866
Practice Address - Country:US
Practice Address - Phone:317-845-5100
Practice Address - Fax:317-845-5200
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-11-25
Last Update Date:2014-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12010747A122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200533220Medicaid