Provider Demographics
NPI:1740659598
Name:BRITE SMILE DENTAL GROUP PC
Entity type:Organization
Organization Name:BRITE SMILE DENTAL GROUP PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
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:703-368-5885
Mailing Address - Street 1:8577 SUDLEY RD STE B
Mailing Address - Street 2:
Mailing Address - City:MANASSAS
Mailing Address - State:VA
Mailing Address - Zip Code:20110-3860
Mailing Address - Country:US
Mailing Address - Phone:703-368-5885
Mailing Address - Fax:703-368-1852
Practice Address - Street 1:8577 SUDLEY RD STE B
Practice Address - Street 2:
Practice Address - City:MANASSAS
Practice Address - State:VA
Practice Address - Zip Code:20110-3860
Practice Address - Country:US
Practice Address - Phone:703-368-5885
Practice Address - Fax:703-368-1852
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-09-23
Last Update Date:2015-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0401412648261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD026866600Medicaid