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General NPI Number Information
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NPI Number | 1710878509
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Entity Type | Individual
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Provider Name | SUBRAMONY BHAGAVATHEESWARAN
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Gender | Male
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Dates
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Enumeration Date | 07/10/2025
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Last Update Date | 07/10/2025
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Provider Practice Location Address
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Address Line | 5341 W FOND DU LAC AVE
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City | MILWAUKEE
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State | WI
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Zip | 53216-1365
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Country | US
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Telephone | 82-741-4871
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Fax |
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Provider Business Mailing Address
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Address Line | 3660 S RIVERSHIRE DR APT 4
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City | GREENFIELD
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State | WI
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Zip | 53228-1167
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Country | US
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Telephone | 510-962-1344
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | 6001894-15
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License Number State | WI
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