Healthcare Provider Details

I. General information

NPI: 1003088873
Provider Name (Legal Business Name): BRIGHT SMILES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/01/2008
Last Update Date: 04/01/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

907 PAVILION CT
MCDONOUGH GA
30253-6665
US

IV. Provider business mailing address

907 PAVILION CT
MCDONOUGH GA
30253-6665
US

V. Phone/Fax

Practice location:
  • Phone: 678-583-8536
  • Fax: 678-583-8657
Mailing address:
  • Phone: 678-583-8536
  • Fax: 678-583-8657

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License NumberDN012649
License Number StateGA

VIII. Authorized Official

Name: DR. SHUNDA L THOMPSON
Title or Position: OWNER
Credential: DDS
Phone: 678-583-8536