| Entity Name: | BRIGHT SMILE DENTAL LLC |
| Jurisdiction: | FLORIDA |
| Filing Type: | Florida Limited Liability Co. |
| Status: | Active |
| Date Filed: | 11 Oct 2024 (4 months ago) |
| Document Number: | L24000436592 |
| FEI/EIN Number | 33-1810753 |
| Address: | 1805 MYRTLE AVE N, JACKSONVILLE, FL, 32209 |
| Mail Address: | 1805 MYRTLE AVE N, JACKSONVILLE, FL, 32209 |
| ZIP code: | 32209 |
| County: | Duval |
| Place of Formation: | FLORIDA |
| NPI | Enumeration Date | Last Update Date | Mailing Address | Practice Location Address | |||||||||||||||||||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1225421662 | 2015-03-10 | 2015-03-10 | 8010 SUNPORT DR STE 115, ORLANDO, FL, 328097897, US | 8010 SUNPORT DR STE 115, ORLANDO, FL, 328097897, US | |||||||||||||||||||||||||||||||||||||||
|
|||||||||||||||||||||||||||||||||||||||||||
| Phone | +1 407-412-7887 |
| Fax | 4076418932 |
Authorized person
| Name | MRS. SIRIN THANASASAVAT |
| Role | DENTIST |
| Phone | 4074127887 |
Taxonomy
| Taxonomy Code | 1223G0001X - General Practice Dentistry |
| License Number | DN17989 |
| State | FL |
| Is Primary | Yes |
| Taxonomy Code | 1223G0001X - General Practice Dentistry |
| License Number | DN17990 |
| State | FL |
| Is Primary | No |
Other Provider Identifiers
| Issuer | MEDICAID |
| Number | 076828600 |
| State | FL |
| Issuer | MEDICAID |
| Number | 625034838 |
| State | FL |
| Name | Role | Address |
|---|---|---|
| DE ALBUQUERQUE FERNANDO C | Agent | 1805 MYRTLE AVE N, JACKSONVILLE, FL, 32209 |
| Name | Role | Address |
|---|---|---|
| DE ALBUQUERQUE FERNANDO C | Manager | 1805 MYRTLE AVE N, JACKSONVILLE, FL, 32209 |
| Name | Date |
|---|---|
| Florida Limited Liability | 2024-10-11 |
Date of last update: 01 Feb 2025
Sources: Florida Department of State
