=====================================================
General NPI Number Information
=====================================================
NPI Number | 1558768929
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BRILLIANT SMILES DENTAL HYGIENE LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/01/2014
-----------------------------------------------------
Last Update Date | 12/01/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 87 HIGHWAY 133
-----------------------------------------------------
City | PAONIA
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 81428
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 970-527-5100
-----------------------------------------------------
Fax | 970-527-5101
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 1173
-----------------------------------------------------
City | PAONIA
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 81428-1173
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 970-527-5100
-----------------------------------------------------
Fax | 970-527-5101
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | JENNIFER D KENDALL
-----------------------------------------------------
Credential | RDH
-----------------------------------------------------
Telephone | 970-527-5100
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 124Q00000X
-----------------------------------------------------
Taxonomy Name | Dental Hygienist
-----------------------------------------------------
License Number | 903219
-----------------------------------------------------
License Number State | CO
-----------------------------------------------------