Provider Demographics
NPI:1649589326
Name:BHAVAN, PRIYA ISHWAR (DDS)
Entity Type:Individual
Prefix:DR
First Name:PRIYA
Middle Name:ISHWAR
Last Name:BHAVAN
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4000 ILLAHE HILL RD S
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97302-9708
Mailing Address - Country:US
Mailing Address - Phone:503-399-0905
Mailing Address - Fax:
Practice Address - Street 1:1680 CHAMBERS ST
Practice Address - Street 2:SUITE 204
Practice Address - City:EUGENE
Practice Address - State:OR
Practice Address - Zip Code:97402-3655
Practice Address - Country:US
Practice Address - Phone:541-345-2042
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-09-29
Last Update Date:2010-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD95131223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice