Provider Demographics
NPI:1689825622
Name:BIANCO, BERNARDO FAUSTO (DMD)
Entity Type:Individual
Prefix:DR
First Name:BERNARDO
Middle Name:FAUSTO
Last Name:BIANCO
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1382 N LOOP PKWY
Mailing Address - Street 2:
Mailing Address - City:ST AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32095-4865
Mailing Address - Country:US
Mailing Address - Phone:321-663-3119
Mailing Address - Fax:
Practice Address - Street 1:1601 SW ARCHER RD
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32608-1135
Practice Address - Country:US
Practice Address - Phone:352-548-6000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-10-08
Last Update Date:2022-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADNO13805122300000X
GADN0138051223P0300X
FLDN228121223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics
No122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLDN22812OtherDENTAL LICENSE NUMBER