Healthcare Provider Details

I. General information

NPI: 1780232827
Provider Name (Legal Business Name): PRANAV BHIDE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/02/2019
Last Update Date: 08/19/2020
Certification Date: 08/19/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

430 MAIN ST
GREEN BAY WI
54301-5115
US

IV. Provider business mailing address

206 N LAFAYETTE AVE APT 4
ROYAL OAK MI
48067-4817
US

V. Phone/Fax

Practice location:
  • Phone: 201-492-4864
  • Fax:
Mailing address:
  • Phone: 201-492-4864
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number2901022830
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code1223P0700X
TaxonomyProsthodontics
License Number1002418-15
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: