Provider Demographics
NPI:1316399876
Name:BRIGHT SMILE DENTAL
Entity Type:Organization
Organization Name:BRIGHT SMILE DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:JONATHAN
Authorized Official - Middle Name:
Authorized Official - Last Name:FLAKSMAN
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:847-962-1057
Mailing Address - Street 1:430 BARRON BLVD
Mailing Address - Street 2:
Mailing Address - City:GRAYSLAKE
Mailing Address - State:IL
Mailing Address - Zip Code:60030-1666
Mailing Address - Country:US
Mailing Address - Phone:847-543-4200
Mailing Address - Fax:
Practice Address - Street 1:430 BARRON BLVD
Practice Address - Street 2:
Practice Address - City:GRAYSLAKE
Practice Address - State:IL
Practice Address - Zip Code:60030-1666
Practice Address - Country:US
Practice Address - Phone:847-543-4200
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-07-08
Last Update Date:2016-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019030839122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty