Healthcare Provider Details

I. General information

NPI: 1689825622
Provider Name (Legal Business Name): BERNARDO FAUSTO BIANCO DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/08/2008
Last Update Date: 06/30/2022
Certification Date: 06/30/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1601 SW ARCHER RD
GAINESVILLE FL
32608-1135
US

IV. Provider business mailing address

1382 N LOOP PKWY
ST AUGUSTINE FL
32095-4865
US

V. Phone/Fax

Practice location:
  • Phone: 352-548-6000
  • Fax:
Mailing address:
  • Phone: 321-663-3119
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License NumberDNO13805
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License NumberDN013805
License Number StateGA
# 3
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License NumberDN22812
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: