Provider Demographics
NPI:1659452993
Name:BHALLA, PRIYANKA (DDS)
Entity type:Individual
Prefix:DR
First Name:PRIYANKA
Middle Name:
Last Name:BHALLA
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 1:14427 CULVER DR
Mailing Address - Street 2:
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92604-0305
Mailing Address - Country:US
Mailing Address - Phone:949-733-0486
Mailing Address - Fax:949-733-0489
Practice Address - Street 1:17691 MANCHESTER AVE
Practice Address - Street 2:
Practice Address - City:IRVINE
Practice Address - State:CA
Practice Address - Zip Code:92614-6647
Practice Address - Country:US
Practice Address - Phone:917-576-2640
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-17
Last Update Date:2013-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY052325122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02678857Medicaid