Healthcare Provider Details

I. General information

NPI: 1154191153
Provider Name (Legal Business Name): ISMILE BRIGHT LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/02/2024
Last Update Date: 01/24/2025
Certification Date: 01/24/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

24795 STATE ROAD 54
LUTZ FL
33559
US

IV. Provider business mailing address

8048 PRAISE DR
TAMPA FL
33625-3744
US

V. Phone/Fax

Practice location:
  • Phone: 813-733-0007
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. ISIS EL GHANNAM
Title or Position: OWNER
Credential:
Phone: 786-716-1589