MEDICARE: BRILLIANT SMILES DENTAL, PC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	046446	NY

General Provider Information

NPI Number	:	1588834014
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BRILLIANT SMILES DENTAL, PC

Provider Business Mailing Address
First Line	:	820 FLATBUSH AVE
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11226-3102
Country	:	US
Telephone Number	:	718-693-9811
Fax Number	:	718-693-2577

Provider Business Practice Location Address
First Line	:	820 FLATBUSH AVE
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11226-3102
Country	:	US
Telephone Number	:	718-693-9811
Fax Number	:	718-693-2577

Authorized Official
Title or Position	:	PRESIDENT
Name	:	HUSSEIN Y ABDELWAHAB
Credential	:	DDS
Telephone Number	:	718-693-9811

Provider Enumeration Date	:	03/12/2008
Last Update Date	:	01/13/2009

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