Healthcare Provider Details

I. General information

NPI: 1003190661
Provider Name (Legal Business Name): BRIGHTER SMILES FAMILY DENTISTRY, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/30/2011
Last Update Date: 09/30/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

947 S LAKE BLVD SUITE A
MAHOPAC NY
10541-3254
US

IV. Provider business mailing address

947 S LAKE BLVD SUITE A
MAHOPAC NY
10541-3254
US

V. Phone/Fax

Practice location:
  • Phone: 845-621-2424
  • Fax: 845-621-1360
Mailing address:
  • Phone: 845-621-2424
  • Fax: 845-621-1360

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number049023
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number039667-1
License Number StateNY
# 3
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number053114-1
License Number StateNY

VIII. Authorized Official

Name: CHRISTOPHER SUN LEE
Title or Position: PRESIDENT
Credential: D.D.S
Phone: 845-621-2424