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General NPI Number Information
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NPI Number | 1023836673
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Entity Type | Organization
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Legal Business Name | SMILE BRILLIANT VENTURES
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Dates
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Enumeration Date | 10/02/2024
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Last Update Date | 10/02/2024
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Provider Practice Location Address
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Address Line | 1645 HEADLAND DR
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City | FENTON
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State | MO
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Zip | 63026-2836
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Country | US
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Telephone | 855-944-8361
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Fax |
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Provider Business Mailing Address
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Address Line | 1645 HEADLAND DR
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City | FENTON
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State | MO
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Zip | 63026-2836
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Country | US
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Telephone | 855-944-8361
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Fax |
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Authorized Official
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Title or Position | BUSINESS OWNER
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Name | MR. MICHAEL BLUESTONE
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Credential |
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Telephone | 314-409-3598
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 292200000X
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Taxonomy Name | Dental Laboratory
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License Number |
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License Number State |
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