Provider Demographics
NPI:1710595509
Name:BRIGHT SMILES PEDIATRIC DENTISTRY NASSAU LLC
Entity Type:Organization
Organization Name:BRIGHT SMILES PEDIATRIC DENTISTRY NASSAU LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:STACEY
Authorized Official - Middle Name:
Authorized Official - Last Name:VEAL
Authorized Official - Suffix:
Authorized Official - Credentials:MHA
Authorized Official - Phone:904-584-9004
Mailing Address - Street 1:196 EVEREST LN STE 1
Mailing Address - Street 2:
Mailing Address - City:SAINT JOHNS
Mailing Address - State:FL
Mailing Address - Zip Code:32259-4103
Mailing Address - Country:US
Mailing Address - Phone:904-584-9004
Mailing Address - Fax:
Practice Address - Street 1:960135 GATEWAY BLVD
Practice Address - Street 2:
Practice Address - City:FERNANDINA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32034-9120
Practice Address - Country:US
Practice Address - Phone:904-584-9004
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BRIGHT SMILES PEDIATRIC DENTISTRY NASSAU LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2020-07-17
Last Update Date:2020-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty