=====================================================
General NPI Number Information
=====================================================
NPI Number | 1841545571
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BRIGHTER IMAGE DENTAL HYGIENE SPA, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/18/2012
-----------------------------------------------------
Last Update Date | 07/18/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 115 ELK AVE. SUITE C SUITE 1442
-----------------------------------------------------
City | CRESTED BUTTE
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 81224-1442
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 970-275-5000
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 115 ELK AVE. SUITE C
-----------------------------------------------------
City | CRESTED BUTTE
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 81224-1442
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 970-275-5000
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | RDH, OWNER
-----------------------------------------------------
Name | MRS. PATRICIA KUBISIAK
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 970-275-5000
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 124Q00000X
-----------------------------------------------------
Taxonomy Name | Dental Hygienist
-----------------------------------------------------
License Number | 903880
-----------------------------------------------------
License Number State | CO
-----------------------------------------------------