Healthcare Provider Details

I. General information

NPI: 1881922953
Provider Name (Legal Business Name): BRITE SMILES INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/30/2009
Last Update Date: 11/30/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

320 3RD ST NW
FARIBAULT MN
55021-5195
US

IV. Provider business mailing address

4366 270TH ST E PO BOX 237
MEDFORD MN
55049-8001
US

V. Phone/Fax

Practice location:
  • Phone: 507-475-0628
  • Fax: 507-446-1098
Mailing address:
  • Phone: 507-475-0628
  • Fax: 507-446-1098

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License NumberH6616
License Number StateMN

VIII. Authorized Official

Name: MRS. RENAE DAWN BLOME
Title or Position: EXECUTIVE DIRECTOR
Credential: RDH
Phone: 507-475-0628