Provider Demographics
NPI:1598114233
Name:BRIGHT SMILES PEDIATRIC DENTISTRY, PLLC
Entity Type:Organization
Organization Name:BRIGHT SMILES PEDIATRIC DENTISTRY, PLLC
Other - Org Name:BRIGHT SMILES PEDIATRIC DENTISTRY
Other - Org Type:Other Name
Authorized Official - Title/Position:OWNER/MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:BRYAN
Authorized Official - Middle Name:MATTHEW
Authorized Official - Last Name:BRIGHT
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:859-433-6146
Mailing Address - Street 1:196 EVEREST LN UNIT 1
Mailing Address - Street 2:
Mailing Address - City:SAINT JOHNS
Mailing Address - State:FL
Mailing Address - Zip Code:32259
Mailing Address - Country:US
Mailing Address - Phone:904-239-1714
Mailing Address - Fax:
Practice Address - Street 1:196 EVEREST LN UNIT 1
Practice Address - Street 2:
Practice Address - City:SAINT JOHNS
Practice Address - State:FL
Practice Address - Zip Code:32259
Practice Address - Country:US
Practice Address - Phone:904-239-1714
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-06-03
Last Update Date:2016-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN217341223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty