Provider Demographics
NPI:1235862889
Name:BRILLIANT SMILES PEDIATRIC DENTISTRY, LLC
Entity Type:Organization
Organization Name:BRILLIANT SMILES PEDIATRIC DENTISTRY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER - PEDIATRIC DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:SUFFIYAH
Authorized Official - Middle Name:
Authorized Official - Last Name:WEBB
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:862-955-2285
Mailing Address - Street 1:243 HALSEY ST
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07102-3746
Mailing Address - Country:US
Mailing Address - Phone:862-955-2285
Mailing Address - Fax:
Practice Address - Street 1:237 HALSEY ST
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:NJ
Practice Address - Zip Code:07102
Practice Address - Country:US
Practice Address - Phone:862-955-2285
Practice Address - Fax:862-367-8219
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-07-01
Last Update Date:2022-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0254576Medicaid