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General NPI Number Information
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NPI Number | 1538472477
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Entity Type | Organization
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Legal Business Name | BRIGHTSMILES PEDIATRIC DENTISTRY
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Dates
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Enumeration Date | 07/20/2010
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Last Update Date | 02/16/2022
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Provider Practice Location Address
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Address Line | 2550 W ADDISON ST STE A17
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City | CHICAGO
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State | IL
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Zip | 60618-5939
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Country | US
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Telephone | 773-423-6050
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Fax |
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Provider Business Mailing Address
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Address Line | 2550 W ADDISON ST STE A17
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City | CHICAGO
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State | IL
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Zip | 60618-5939
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Country | US
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Telephone | 773-423-6050
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Fax |
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Authorized Official
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Title or Position | PEDIATRIC DENTISTRY
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Name | DR. H. JOHNNY I KUTTAB
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Credential | D.D.S.
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Telephone | 847-971-8847
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223P0221X
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Taxonomy Name | Pediatric Dentistry
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License Number | 019.027640
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License Number State | IL
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