Provider Demographics
NPI:1942634571
Name:BRITE SMILE DENTAL GROUP, P.C.
Entity Type:Organization
Organization Name:BRITE SMILE DENTAL GROUP, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JAEWON
Authorized Official - Middle Name:
Authorized Official - Last Name:YOON
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:410-443-5584
Mailing Address - Street 1:10176 BALTIMORE NATIONAL PIKE STE 207
Mailing Address - Street 2:
Mailing Address - City:ELLICOTT CITY
Mailing Address - State:MD
Mailing Address - Zip Code:21042-3652
Mailing Address - Country:US
Mailing Address - Phone:410-443-5584
Mailing Address - Fax:
Practice Address - Street 1:10176 BALTIMORE NATIONAL PIKE STE 207
Practice Address - Street 2:
Practice Address - City:ELLICOTT CITY
Practice Address - State:MD
Practice Address - Zip Code:21042-3652
Practice Address - Country:US
Practice Address - Phone:410-443-5584
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-08-30
Last Update Date:2013-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD14679261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD026866600Medicaid