Provider Demographics
NPI:1912085390
Name:SMILE BRIGHT DENTURE CENTER LLC
Entity Type:Organization
Organization Name:SMILE BRIGHT DENTURE CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTURIST
Authorized Official - Prefix:MR
Authorized Official - First Name:DUNG
Authorized Official - Middle Name:Q
Authorized Official - Last Name:PHAM
Authorized Official - Suffix:
Authorized Official - Credentials:DN
Authorized Official - Phone:425-355-4409
Mailing Address - Street 1:315 E CASINO RD
Mailing Address - Street 2:SUITE B
Mailing Address - City:EVERETT
Mailing Address - State:WA
Mailing Address - Zip Code:98208-1846
Mailing Address - Country:US
Mailing Address - Phone:425-355-4409
Mailing Address - Fax:
Practice Address - Street 1:315 E CASINO RD
Practice Address - Street 2:SUITE B
Practice Address - City:EVERETT
Practice Address - State:WA
Practice Address - Zip Code:98208-1846
Practice Address - Country:US
Practice Address - Phone:425-355-4409
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SMILE BRIGHT DENTURE CENTER, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-11-01
Last Update Date:2013-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADN00000360122400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122400000XDental ProvidersDenturistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA504-5992Medicaid
WA504-9556Medicaid
WA=========OtherREGENCE BLUE SHIELD
WA=========OtherWASHINGTON DENTAL SERV.
WA=========OtherPREMERA BLUE CROSS
WA504-9556Medicaid
WA=========OtherMETROPLITAN LIFE INS.
WA=========OtherCIGNA DENTAL PPO
WA504-5992Medicaid
WA=========OtherGUARDIAN INSURANCE
WA=========OtherTHE STANDARD INSURANCE