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General NPI Number Information
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NPI Number | 1710595509
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Entity Type | Organization
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Legal Business Name | BRIGHT SMILES PEDIATRIC DENTISTRY NASSAU LLC
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Dates
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Enumeration Date | 07/17/2020
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Last Update Date | 07/17/2020
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Provider Practice Location Address
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Address Line | 960135 GATEWAY BLVD
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City | FERNANDINA BEACH
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State | FL
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Zip | 32034-9120
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Country | US
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Telephone | 904-584-9004
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Fax |
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Provider Business Mailing Address
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Address Line | 196 EVEREST LN STE 1
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City | SAINT JOHNS
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State | FL
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Zip | 32259-4103
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Country | US
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Telephone | 904-584-9004
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Fax |
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Authorized Official
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Title or Position | PRACTICE MANAGER
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Name | STACEY VEAL
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Credential | MHA
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Telephone | 904-584-9004
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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 |
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License Number State |
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