Provider Demographics
NPI:1578683892
Name:BAHL, MANOJ K (DDS)
Entity Type:Individual
Prefix:DR
First Name:MANOJ
Middle Name:K
Last Name:BAHL
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:40 W 73RD AVE
Mailing Address - Street 2:
Mailing Address - City:MERRILLVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46410-3979
Mailing Address - Country:US
Mailing Address - Phone:219-769-3055
Mailing Address - Fax:219-769-4674
Practice Address - Street 1:40 W 73RD AVE
Practice Address - Street 2:
Practice Address - City:MERRILLVILLE
Practice Address - State:IN
Practice Address - Zip Code:46410-3979
Practice Address - Country:US
Practice Address - Phone:219-769-3305
Practice Address - Fax:219-769-4674
Is Sole Proprietor?:No
Enumeration Date:2007-03-30
Last Update Date:2021-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY50052656122300000X
IL0190282181223G0001X
IN12011727A1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist