Healthcare Provider Details

I. General information

NPI: 1184340622
Provider Name (Legal Business Name): BRIGHT DENTAL STUDIO PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/17/2022
Last Update Date: 10/31/2022
Certification Date: 10/31/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

120 W COLUMBIA ST
SAN AUGUSTINE TX
75972-1904
US

IV. Provider business mailing address

120 W COLUMBIA ST
SAN AUGUSTINE TX
75972-1904
US

V. Phone/Fax

Practice location:
  • Phone: 936-288-3520
  • Fax: 936-288-5076
Mailing address:
  • Phone: 936-288-3520
  • Fax: 936-288-5076

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QS0112X
TaxonomyOral and Maxillofacial Surgery Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: SIDNEY J FOWLER
Title or Position: OWNER
Credential: DDS
Phone: 936-564-9401