MEDICARE: BRIGHTSIDE ORAL SURGERY LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	204E00000X	Oral & Maxillofacial Surgery (D.M.D.)

General Provider Information

NPI Number	:	1083569396
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BRIGHTSIDE ORAL SURGERY LLC

Provider Business Mailing Address
First Line	:	5682 S 3500 W UNIT A
Second Line	:
City	:	ROY
State	:	UT
Zip	:	84067-9108
Country	:	US
Telephone Number	:	801-773-9828
Fax Number	:	801-773-9828

Provider Business Practice Location Address
First Line	:	5682 S 3500 W UNIT A
Second Line	:
City	:	ROY
State	:	UT
Zip	:	84067-9108
Country	:	US
Telephone Number	:	801-773-9828
Fax Number	:	801-773-9828

Authorized Official
Title or Position	:	CREDENTIALING MANAGER
Name	:	EBONIE GONZALES
Credential	:
Telephone Number	:	505-850-3769

Provider Enumeration Date	:	03/02/2026
Last Update Date	:	03/02/2026

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Directions to “BRIGHTSIDE ORAL SURGERY LLC ” Practice Location

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