Provider Demographics
NPI:1710274477
Name:BRILLIANT SMILES DENTAL GROUP - PINE HILL LLC
Entity Type:Organization
Organization Name:BRILLIANT SMILES DENTAL GROUP - PINE HILL LLC
Other - Org Name:HOMETOWN FAMILY DENTISTRY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MICHELLE
Authorized Official - Middle Name:
Authorized Official - Last Name:AITKEN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:856-346-0700
Mailing Address - Street 1:610 BLACKWOOD CLEMENTON RD STE E
Mailing Address - Street 2:
Mailing Address - City:PINE HILL
Mailing Address - State:NJ
Mailing Address - Zip Code:08021-5213
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:610 BLACKWOOD CLEMENTON RD STE E
Practice Address - Street 2:
Practice Address - City:PINE HILL
Practice Address - State:NJ
Practice Address - Zip Code:08021-5213
Practice Address - Country:US
Practice Address - Phone:856-346-0700
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-07-01
Last Update Date:2011-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJDI02244000122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty