Provider Demographics
NPI:1336804178
Name:BRIGHT SMILES DENTISTRY LLC
Entity Type:Organization
Organization Name:BRIGHT SMILES DENTISTRY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO OWNER/OPERATIONS MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:PRASANNA KUMARI
Authorized Official - Middle Name:V
Authorized Official - Last Name:MUDDANA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:262-563-9100
Mailing Address - Street 1:13500 W CAPITOL DR STE 202
Mailing Address - Street 2:
Mailing Address - City:BROOKFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:53005-2444
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:13500 W CAPITOL DR STE 103
Practice Address - Street 2:
Practice Address - City:BROOKFIELD
Practice Address - State:WI
Practice Address - Zip Code:53005-2444
Practice Address - Country:US
Practice Address - Phone:262-563-9100
Practice Address - Fax:262-563-9101
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-11-06
Last Update Date:2021-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1396090734Medicaid
WI1376806893Medicaid