Provider Demographics
NPI:1558941633
Name:CHANDRA, BHAWNA
Entity Type:Individual
Prefix:
First Name:BHAWNA
Middle Name:
Last Name:CHANDRA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3727 N GOLDENROD RD STE 108
Mailing Address - Street 2:
Mailing Address - City:WINTER PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32792-8611
Mailing Address - Country:US
Mailing Address - Phone:407-671-0001
Mailing Address - Fax:
Practice Address - Street 1:3727 N GOLDENROD RD STE 108
Practice Address - Street 2:
Practice Address - City:WINTER PARK
Practice Address - State:FL
Practice Address - Zip Code:32792-8611
Practice Address - Country:US
Practice Address - Phone:407-671-0001
Practice Address - Fax:407-671-3496
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-12
Last Update Date:2021-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
FLDN258271223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program