Provider Demographics
NPI:1427519529
Name:BRIGHT SMILES DENTAL PROGRAM
Entity type:Organization
Organization Name:BRIGHT SMILES DENTAL PROGRAM
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:BLAKE
Authorized Official - Middle Name:
Authorized Official - Last Name:DARSOW
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:651-602-7537
Mailing Address - Street 1:153 CESAR CHAVEZ ST
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55107-2226
Mailing Address - Country:US
Mailing Address - Phone:651-602-7500
Mailing Address - Fax:651-602-7580
Practice Address - Street 1:153 CESAR CHAVEZ ST
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55107-2226
Practice Address - Country:US
Practice Address - Phone:651-602-7500
Practice Address - Fax:651-602-7580
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WEST SIDE COMMUNITY HEALTH SERVICE
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2019-03-29
Last Update Date:2019-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental