Provider Demographics
NPI:1023836673
Name:SMILE BRILLIANT VENTURES
Entity type:Organization
Organization Name:SMILE BRILLIANT VENTURES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:BLUESTONE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:314-409-3598
Mailing Address - Street 1:1645 HEADLAND DR
Mailing Address - Street 2:
Mailing Address - City:FENTON
Mailing Address - State:MO
Mailing Address - Zip Code:63026-2836
Mailing Address - Country:US
Mailing Address - Phone:855-944-8361
Mailing Address - Fax:
Practice Address - Street 1:1645 HEADLAND DR
Practice Address - Street 2:
Practice Address - City:FENTON
Practice Address - State:MO
Practice Address - Zip Code:63026-2836
Practice Address - Country:US
Practice Address - Phone:855-944-8361
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-10-02
Last Update Date:2024-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes292200000XLaboratoriesDental Laboratory