=====================================================
General NPI Number Information
=====================================================
NPI Number | 1376083006
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BRIGHT SMILE FAMILY DENTAL
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/28/2017
-----------------------------------------------------
Last Update Date | 02/28/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 12601 WESTERN AVE UNIT B
-----------------------------------------------------
City | BLUE ISLAND
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60406-1749
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 708-293-1903
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 12601 WESTERN AVE UNIT B
-----------------------------------------------------
City | BLUE ISLAND
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60406-1749
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DDS
-----------------------------------------------------
Name | GEHAN ADAM
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 708-293-1903
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 019027109
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------