Provider Demographics
NPI:1568835080
Name:BRILLIANT SMILES ORTHODONTICS
Entity Type:Organization
Organization Name:BRILLIANT SMILES ORTHODONTICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:
Authorized Official - First Name:ROMIA
Authorized Official - Middle Name:
Authorized Official - Last Name:GOFF
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:321-914-3972
Mailing Address - Street 1:455 MAGNOLIA AVENUE
Mailing Address - Street 2:
Mailing Address - City:MERRITT ISLAND
Mailing Address - State:FL
Mailing Address - Zip Code:32952
Mailing Address - Country:US
Mailing Address - Phone:321-914-3972
Mailing Address - Fax:
Practice Address - Street 1:455 MAGNOLIA AVENUE
Practice Address - Street 2:
Practice Address - City:MERRITT ISLAND
Practice Address - State:FL
Practice Address - Zip Code:32952
Practice Address - Country:US
Practice Address - Phone:321-914-3972
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-11-05
Last Update Date:2015-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN17172302R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302R00000XManaged Care OrganizationsHealth Maintenance Organization