Provider Demographics
NPI:1588058903
Name:BRIGHTON DENTAL,LLC
Entity type:Organization
Organization Name:BRIGHTON DENTAL,LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MISS
Authorized Official - First Name:CORNELIA
Authorized Official - Middle Name:JANNA
Authorized Official - Last Name:BECK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:843-237-3525
Mailing Address - Street 1:P.O. BOX 2550
Mailing Address - Street 2:
Mailing Address - City:MURRELLS INLET
Mailing Address - State:SC
Mailing Address - Zip Code:29576
Mailing Address - Country:US
Mailing Address - Phone:843-527-1373
Mailing Address - Fax:843-527-7553
Practice Address - Street 1:1257 N FRASER ST
Practice Address - Street 2:
Practice Address - City:GEORGETOWN
Practice Address - State:SC
Practice Address - Zip Code:29440-4086
Practice Address - Country:US
Practice Address - Phone:843-527-1373
Practice Address - Fax:843-527-7553
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-03-24
Last Update Date:2015-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC2222122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCZZ-2222Medicaid
SCZZ-2222Medicaid