Provider Demographics
NPI:1215209861
Name:BRILLIANT SMILE DENTAL, P.C.
Entity Type:Organization
Organization Name:BRILLIANT SMILE DENTAL, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:NICOLE
Authorized Official - Middle Name:NGA
Authorized Official - Last Name:LUONG
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:503-708-8059
Mailing Address - Street 1:12720 SE STARK ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97233-1539
Mailing Address - Country:US
Mailing Address - Phone:503-708-8059
Mailing Address - Fax:
Practice Address - Street 1:12720 SE STARK ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97233-1539
Practice Address - Country:US
Practice Address - Phone:503-252-6133
Practice Address - Fax:503-257-6886
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-01-28
Last Update Date:2014-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD7803122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR227117Medicaid