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General NPI Number Information
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NPI Number | 1306220496
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Entity Type | Organization
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Legal Business Name | BRILLIANT SMILES DENTAL GROUP - HAVERTOWN
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Dates
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Enumeration Date | 07/17/2015
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Last Update Date | 07/17/2015
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Provider Practice Location Address
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Address Line | 301 W CHESTER PIKE SUITE 202
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City | HAVERTOWN
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State | PA
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Zip | 19083-4530
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Country | US
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Telephone | 610-789-9400
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Fax | 610-789-2841
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Provider Business Mailing Address
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Address Line | 301 W CHESTER PIKE SUITE 202
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City | HAVERTOWN
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State | PA
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Zip | 19083-4530
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Country | US
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Telephone | 610-789-9400
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Fax | 610-789-2841
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Authorized Official
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Title or Position | OWNER
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Name | MICHELLE AITKEN
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Credential | DDS
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Telephone | 610-789-9400
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QD0000X
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Taxonomy Name | Dental Clinic/Center
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License Number | DS035966
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License Number State | PA
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