MEDICARE: BRILLIANT SMILES DENTAL GROUP - MAGNOLIA 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	122300000X	Dentist	DI02244000	NJ

General Provider Information

NPI Number	:	1538455324
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BRILLIANT SMILES DENTAL GROUP - MAGNOLIA LLC

Provider Business Mailing Address
First Line	:	402 WHITE HORSE PIKE S
Second Line	:
City	:	MAGNOLIA
State	:	NJ
Zip	:	08049-1061
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	402 WHITE HORSE PIKE S
Second Line	:
City	:	MAGNOLIA
State	:	NJ
Zip	:	08049-1061
Country	:	US
Telephone Number	:	856-566-9700
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	DR. MICHELLE AITKEN
Credential	:	DDS
Telephone Number	:	856-566-9700

Provider Enumeration Date	:	06/21/2011
Last Update Date	:	06/21/2011

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