Provider Demographics
NPI:1841473709
Name:BRIGHT SMILE FAMILY DENTISTRY PLLC
Entity type:Organization
Organization Name:BRIGHT SMILE FAMILY DENTISTRY PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ELI
Authorized Official - Middle Name:T
Authorized Official - Last Name:JARJOURA
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:405-229-1234
Mailing Address - Street 1:P.O. BOX 8110
Mailing Address - Street 2:
Mailing Address - City:EDMOND
Mailing Address - State:OK
Mailing Address - Zip Code:73083
Mailing Address - Country:US
Mailing Address - Phone:405-844-8887
Mailing Address - Fax:405-844-9625
Practice Address - Street 1:3225 TEAKWOOD LANE
Practice Address - Street 2:
Practice Address - City:EDMOND
Practice Address - State:OK
Practice Address - Zip Code:73013
Practice Address - Country:US
Practice Address - Phone:405-844-8887
Practice Address - Fax:405-844-9625
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-13
Last Update Date:2013-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1223G0001X
OK1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200054280AMedicaid
OK200054290AMedicaid