Healthcare Provider Details

I. General information

NPI: 1649589326
Provider Name (Legal Business Name): PRIYA ISHWAR BHAVAN D.D.S.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/29/2010
Last Update Date: 09/29/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1680 CHAMBERS ST SUITE 204
EUGENE OR
97402-3655
US

IV. Provider business mailing address

4000 ILLAHE HILL RD S
SALEM OR
97302-9708
US

V. Phone/Fax

Practice location:
  • Phone: 541-345-2042
  • Fax:
Mailing address:
  • Phone: 503-399-0905
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberD9513
License Number StateOR

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: