Provider Demographics
NPI:1538472477
Name:BRIGHTSMILES PEDIATRIC DENTISTRY
Entity Type:Organization
Organization Name:BRIGHTSMILES PEDIATRIC DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PEDIATRIC DENTISTRY
Authorized Official - Prefix:DR
Authorized Official - First Name:H. JOHNNY
Authorized Official - Middle Name:I
Authorized Official - Last Name:KUTTAB
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:847-971-8847
Mailing Address - Street 1:2550 W ADDISON ST STE A17
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60618-5939
Mailing Address - Country:US
Mailing Address - Phone:773-423-6050
Mailing Address - Fax:
Practice Address - Street 1:2550 W ADDISON ST STE A17
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60618-5939
Practice Address - Country:US
Practice Address - Phone:773-423-6050
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-07-20
Last Update Date:2022-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019.0276401223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1811155096OtherINDIVIDUAL NPI