Provider Demographics
NPI:1184340622
Name:BRIGHT DENTAL STUDIO PLLC
Entity type:Organization
Organization Name:BRIGHT DENTAL STUDIO PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SIDNEY
Authorized Official - Middle Name:J
Authorized Official - Last Name:FOWLER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:936-564-9401
Mailing Address - Street 1:120 W COLUMBIA ST
Mailing Address - Street 2:
Mailing Address - City:SAN AUGUSTINE
Mailing Address - State:TX
Mailing Address - Zip Code:75972-1904
Mailing Address - Country:US
Mailing Address - Phone:936-288-3520
Mailing Address - Fax:936-288-5076
Practice Address - Street 1:120 W COLUMBIA ST
Practice Address - Street 2:
Practice Address - City:SAN AUGUSTINE
Practice Address - State:TX
Practice Address - Zip Code:75972-1904
Practice Address - Country:US
Practice Address - Phone:936-288-3520
Practice Address - Fax:936-288-5076
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-10-17
Last Update Date:2022-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
No261QS0112XAmbulatory Health Care FacilitiesClinic/CenterOral and Maxillofacial Surgery