=====================================================
General NPI Number Information
=====================================================
NPI Number | 1245620350
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BRIGHT SIDE SLEEP SOLUTIONS, PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/27/2015
-----------------------------------------------------
Last Update Date | 09/09/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 43368 WOODWARD AVE SUITE 100
-----------------------------------------------------
City | BLOOMFIELD HILLS
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48302-5051
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 248-971-7366
-----------------------------------------------------
Fax | 248-971-7439
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 43368 WOODWARD AVE SUITE 100
-----------------------------------------------------
City | BLOOMFIELD HILLS
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48302-5051
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 248-971-7366
-----------------------------------------------------
Fax | 248-971-7439
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MEMBER
-----------------------------------------------------
Name | DR. RANDY T FISHMAN
-----------------------------------------------------
Credential | D.D.S.
-----------------------------------------------------
Telephone | 248-882-2070
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 2901011555
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 332BC3200X
-----------------------------------------------------
Taxonomy Name | Customized Equipment (DME)
-----------------------------------------------------
License Number | 2901011555
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 332B00000X
-----------------------------------------------------
Taxonomy Name | Durable Medical Equipment & Medical Supplies
-----------------------------------------------------
License Number | 2901011555
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------