Provider Demographics
NPI:1013357094
Name:BRILLIANT DENTISTRY
Entity Type:Organization
Organization Name:BRILLIANT DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ADNAN
Authorized Official - Middle Name:
Authorized Official - Last Name:KHAZAAL
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:734-956-5604
Mailing Address - Street 1:28050 FORD RD
Mailing Address - Street 2:SUITE D
Mailing Address - City:GARDEN CITY
Mailing Address - State:MI
Mailing Address - Zip Code:48135-2967
Mailing Address - Country:US
Mailing Address - Phone:734-956-5604
Mailing Address - Fax:734-956-5284
Practice Address - Street 1:28050 FORD RD
Practice Address - Street 2:SUITE D
Practice Address - City:GARDEN CITY
Practice Address - State:MI
Practice Address - Zip Code:48135-2967
Practice Address - Country:US
Practice Address - Phone:734-956-5604
Practice Address - Fax:734-956-5284
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-07-05
Last Update Date:2013-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2901016118122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty