Healthcare Provider Details

I. General information

NPI: 1407631179
Provider Name (Legal Business Name): BRIGHTER DENTAL OF PARK RIDGE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/30/2023
Last Update Date: 08/30/2023
Certification Date: 08/30/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1416 CANFIELD RD
PARK RIDGE IL
60068-5553
US

IV. Provider business mailing address

1416 CANFIELD RD
PARK RIDGE IL
60068-5553
US

V. Phone/Fax

Practice location:
  • Phone: 847-698-0888
  • Fax:
Mailing address:
  • Phone: 847-698-0888
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: ROGER NOUNEH
Title or Position: MANAGING MEMBER
Credential: DMD
Phone: 312-927-8882