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General NPI Number Information
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NPI Number | 1164829032
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Entity Type | Organization
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Legal Business Name | BRIGHTER DENTAL OF OLD TOWN
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Dates
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Enumeration Date | 11/20/2014
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Last Update Date | 11/20/2014
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Provider Practice Location Address
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Address Line | 1254 N WELLS ST
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City | CHICAGO
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State | IL
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Zip | 60610-1981
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Country | US
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Telephone | 312-337-3300
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Fax |
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Provider Business Mailing Address
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Address Line | 1254 N WELLS ST
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City | CHICAGO
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State | IL
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Zip | 60610-1981
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Country | US
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Telephone | 312-337-3300
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Fax |
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Authorized Official
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Title or Position | MANAGING MEMBER
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Name | DR. ROGER NOUNEH
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Credential |
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Telephone | 312-337-3300
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 019029429
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License Number State | IL
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Taxonomy #2
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 019029061
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License Number State | IL
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Taxonomy #3
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 019029936
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License Number State | IL
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Taxonomy #4
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 019029031
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License Number State | IL
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Taxonomy #5
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Taxonomy Code | 1223P0300X
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Taxonomy Name | Periodontics
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License Number | 021001990
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License Number State | IL
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Taxonomy #6
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 019025485
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License Number State | IL
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