Provider Demographics
NPI:1447786579
Name:BRIGHT SMILES ORTHODONTICS
Entity Type:Organization
Organization Name:BRIGHT SMILES ORTHODONTICS
Other - Org Name:SUBURBAN ORTHODONTICS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JASON
Authorized Official - Middle Name:
Authorized Official - Last Name:JONES
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:716-649-5254
Mailing Address - Street 1:2005 NIAGARA FALLS BLVD.
Mailing Address - Street 2:
Mailing Address - City:AMHERST
Mailing Address - State:NY
Mailing Address - Zip Code:14228
Mailing Address - Country:US
Mailing Address - Phone:716-649-5254
Mailing Address - Fax:716-525-1861
Practice Address - Street 1:2005 NIAGARA FALLS BLVD.
Practice Address - Street 2:
Practice Address - City:AMHERST
Practice Address - State:NY
Practice Address - Zip Code:14228
Practice Address - Country:US
Practice Address - Phone:716-649-5254
Practice Address - Fax:716-525-1861
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-05-10
Last Update Date:2017-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY04873111223P0221X
NY05482611223X0400X
NY0441041223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Multi-Specialty
No1223P0221XDental ProvidersDentistPediatric DentistryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03338938Medicaid