Provider Demographics
NPI:1578959953
Name:BRILLIANT SMILES DENTAL HYGIENE SERVICES
Entity Type:Organization
Organization Name:BRILLIANT SMILES DENTAL HYGIENE SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:MELISSA
Authorized Official - Middle Name:
Authorized Official - Last Name:ROSOCHACKI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:616-706-1721
Mailing Address - Street 1:4065 E COMMERCE RD
Mailing Address - Street 2:
Mailing Address - City:COMMERCE TOWNSHIP
Mailing Address - State:MI
Mailing Address - Zip Code:48382-1369
Mailing Address - Country:US
Mailing Address - Phone:616-706-1721
Mailing Address - Fax:
Practice Address - Street 1:4065 E COMMERCE RD
Practice Address - Street 2:
Practice Address - City:COMMERCE TOWNSHIP
Practice Address - State:MI
Practice Address - Zip Code:48382-1369
Practice Address - Country:US
Practice Address - Phone:616-706-1721
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-04-12
Last Update Date:2015-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2902016339124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes124Q00000XDental ProvidersDental HygienistGroup - Single Specialty