Provider Demographics
NPI:1912364860
Name:BRILLIANT SMILE DENTAL, P.C.
Entity Type:Organization
Organization Name:BRILLIANT SMILE DENTAL, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:GENERAL DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:IN KYUNG
Authorized Official - Middle Name:
Authorized Official - Last Name:LEE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:203-235-4930
Mailing Address - Street 1:725 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MERIDEN
Mailing Address - State:CT
Mailing Address - Zip Code:06450-6005
Mailing Address - Country:US
Mailing Address - Phone:203-235-4930
Mailing Address - Fax:203-235-4932
Practice Address - Street 1:725 E MAIN ST
Practice Address - Street 2:
Practice Address - City:MERIDEN
Practice Address - State:CT
Practice Address - Zip Code:06450-6005
Practice Address - Country:US
Practice Address - Phone:203-235-4930
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-01-24
Last Update Date:2023-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CTCT0110251223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty