Provider Demographics
NPI:1306220496
Name:BRILLIANT SMILES DENTAL GROUP - HAVERTOWN
Entity Type:Organization
Organization Name:BRILLIANT SMILES DENTAL GROUP - HAVERTOWN
Other - Org Name:ELEGANT SMILES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MICHELLE
Authorized Official - Middle Name:
Authorized Official - Last Name:AITKEN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:610-789-9400
Mailing Address - Street 1:301 W CHESTER PIKE
Mailing Address - Street 2:SUITE 202
Mailing Address - City:HAVERTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:19083-4530
Mailing Address - Country:US
Mailing Address - Phone:610-789-9400
Mailing Address - Fax:610-789-2841
Practice Address - Street 1:301 W CHESTER PIKE
Practice Address - Street 2:SUITE 202
Practice Address - City:HAVERTOWN
Practice Address - State:PA
Practice Address - Zip Code:19083-4530
Practice Address - Country:US
Practice Address - Phone:610-789-9400
Practice Address - Fax:610-789-2841
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-07-17
Last Update Date:2015-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS035966261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental