Provider Demographics
NPI:1558768929
Name:BRILLIANT SMILES DENTAL HYGIENE LLC
Entity Type:Organization
Organization Name:BRILLIANT SMILES DENTAL HYGIENE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:D
Authorized Official - Last Name:KENDALL
Authorized Official - Suffix:
Authorized Official - Credentials:RDH
Authorized Official - Phone:970-527-5100
Mailing Address - Street 1:PO BOX 1173
Mailing Address - Street 2:
Mailing Address - City:PAONIA
Mailing Address - State:CO
Mailing Address - Zip Code:81428-1173
Mailing Address - Country:US
Mailing Address - Phone:970-527-5100
Mailing Address - Fax:970-527-5101
Practice Address - Street 1:87 HIGHWAY 133
Practice Address - Street 2:
Practice Address - City:PAONIA
Practice Address - State:CO
Practice Address - Zip Code:81428
Practice Address - Country:US
Practice Address - Phone:970-527-5100
Practice Address - Fax:970-527-5101
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-12-01
Last Update Date:2014-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO903219124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes124Q00000XDental ProvidersDental HygienistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO1366844557OtherNPI INDIVIDUAL