Provider Demographics
NPI:1164829032
Name:BRIGHTER DENTAL OF OLD TOWN
Entity Type:Organization
Organization Name:BRIGHTER DENTAL OF OLD TOWN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:ROGER
Authorized Official - Middle Name:
Authorized Official - Last Name:NOUNEH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:312-337-3300
Mailing Address - Street 1:1254 N WELLS ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60610-1981
Mailing Address - Country:US
Mailing Address - Phone:312-337-3300
Mailing Address - Fax:
Practice Address - Street 1:1254 N WELLS ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60610-1981
Practice Address - Country:US
Practice Address - Phone:312-337-3300
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-11-20
Last Update Date:2014-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019025485122300000X
IL019029429122300000X
IL019029061122300000X
IL019029936122300000X
IL019029031122300000X
IL0210019901223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty
No1223P0300XDental ProvidersDentistPeriodonticsGroup - Multi-Specialty