MEDICARE: BRIGHTER IMAGE DENTAL

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	261QD0000X	Dental Clinic/Center	48051	CA

General Provider Information

NPI Number	:	1538327572
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BRIGHTER IMAGE DENTAL

Provider Business Mailing Address
First Line	:	1031 AVENIDA PICO STE 203
Second Line	:
City	:	SAN CLEMENTE
State	:	CA
Zip	:	92673-6356
Country	:	US
Telephone Number	:	949-361-6900
Fax Number	:	949-361-3779

Provider Business Practice Location Address
First Line	:	1031 AVENIDA PICO
Second Line	:	#203
City	:	SAN CLEMENTE
State	:	CA
Zip	:	92673-6352
Country	:	US
Telephone Number	:	949-361-6900
Fax Number	:	949-361-3779

Authorized Official
Title or Position	:	OWNER
Name	:	DR. LE TRAN
Credential	:	DDS
Telephone Number	:	949-361-6900

Provider Enumeration Date	:	05/27/2008
Last Update Date	:	05/27/2008

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