Provider Demographics
NPI:1942852306
Name:BRILLIANT SMILES ODEH LLC
Entity Type:Organization
Organization Name:BRILLIANT SMILES ODEH LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COO
Authorized Official - Prefix:
Authorized Official - First Name:OPAL
Authorized Official - Middle Name:
Authorized Official - Last Name:ANDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:937-376-9975
Mailing Address - Street 1:1289 N MONROE DR
Mailing Address - Street 2:
Mailing Address - City:XENIA
Mailing Address - State:OH
Mailing Address - Zip Code:45385-1655
Mailing Address - Country:US
Mailing Address - Phone:937-376-8252
Mailing Address - Fax:
Practice Address - Street 1:1289 N MONROE DR
Practice Address - Street 2:
Practice Address - City:XENIA
Practice Address - State:OH
Practice Address - Zip Code:45385-1655
Practice Address - Country:US
Practice Address - Phone:937-376-8252
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-07-15
Last Update Date:2022-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty