Provider Demographics
NPI:1457861031
Name:BRITE DENTAL OF BURLESON PA
Entity Type:Organization
Organization Name:BRITE DENTAL OF BURLESON PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:KIM
Authorized Official - Middle Name:T
Authorized Official - Last Name:VAN
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:817-426-3331
Mailing Address - Street 1:664 SW WILSHIRE BLVD
Mailing Address - Street 2:
Mailing Address - City:BURLESON
Mailing Address - State:TX
Mailing Address - Zip Code:76028-5851
Mailing Address - Country:US
Mailing Address - Phone:817-426-3331
Mailing Address - Fax:
Practice Address - Street 1:664 SW WILSHIRE BLVD
Practice Address - Street 2:
Practice Address - City:BURLESON
Practice Address - State:TX
Practice Address - Zip Code:76028-5851
Practice Address - Country:US
Practice Address - Phone:817-426-3331
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-10-09
Last Update Date:2017-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty