MEDICARE: BRIGHTSMILES PEDIATRIC DENTISTRY

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	1223P0221X	Pediatric Dentistry	019.027640	IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1811155096	OTHER	IL	INDIVIDUAL NPI

General Provider Information

NPI Number	:	1538472477
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BRIGHTSMILES PEDIATRIC DENTISTRY

Provider Business Mailing Address
First Line	:	2550 W ADDISON ST STE A17
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60618-5939
Country	:	US
Telephone Number	:	773-423-6050
Fax Number	:

Provider Business Practice Location Address
First Line	:	2550 W ADDISON ST STE A17
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60618-5939
Country	:	US
Telephone Number	:	773-423-6050
Fax Number	:

Authorized Official
Title or Position	:	PEDIATRIC DENTISTRY
Name	:	DR. H. JOHNNY I KUTTAB
Credential	:	D.D.S.
Telephone Number	:	847-971-8847

Provider Enumeration Date	:	07/20/2010
Last Update Date	:	02/16/2022

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