Provider Demographics
NPI:1588835755
Name:BRIGHT SMILE DENTAL CLINIC, LTD.
Entity Type:Organization
Organization Name:BRIGHT SMILE DENTAL CLINIC, LTD.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ABDULHASSAN
Authorized Official - Middle Name:A
Authorized Official - Last Name:TAWOOSI
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:773-546-8317
Mailing Address - Street 1:6027 1/2 W. BELMONT AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60634
Mailing Address - Country:US
Mailing Address - Phone:773-237-4291
Mailing Address - Fax:773-237-4291
Practice Address - Street 1:6027 W BELMONT AVE STE A
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60634-5116
Practice Address - Country:US
Practice Address - Phone:773-237-4291
Practice Address - Fax:773-237-4291
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BRIGHT SMILE DENTAL CLINIC, LTD.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-03-17
Last Update Date:2008-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1518155191Medicaid