Provider Demographics
NPI:1780232827
Name:BHIDE, PRANAV
Entity type:Individual
Prefix:
First Name:PRANAV
Middle Name:
Last Name:BHIDE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:206 N LAFAYETTE AVE APT 4
Mailing Address - Street 2:
Mailing Address - City:ROYAL OAK
Mailing Address - State:MI
Mailing Address - Zip Code:48067-4817
Mailing Address - Country:US
Mailing Address - Phone:201-492-4864
Mailing Address - Fax:
Practice Address - Street 1:430 MAIN ST
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54301-5115
Practice Address - Country:US
Practice Address - Phone:201-492-4864
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-02
Last Update Date:2020-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29010228301223G0001X
WI1002418-151223P0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0700XDental ProvidersDentistProsthodontics
No1223G0001XDental ProvidersDentistGeneral Practice