Basic Information
| Provider Information | |||||||||
| NPI: | 1689825622 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BIANCO | ||||||||
| FirstName: | BERNARDO | ||||||||
| MiddleName: | FAUSTO | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DMD | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | |||||||||
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| OtherMiddleName: | |||||||||
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| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 1382 N LOOP PKWY | ||||||||
| Address2: | |||||||||
| City: | ST AUGUSTINE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 320954865 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3216633119 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1601 SW ARCHER RD | ||||||||
| Address2: | |||||||||
| City: | GAINESVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 326081135 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3525486000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/08/2008 | ||||||||
| LastUpdateDate: | 06/30/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNamePrefix: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 06/30/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X | DNO13805 | GA | N | Dental Providers | Dentist | 1223P0300X | DN013805 | GA | N | Dental Providers | Dentist | Periodontics | 1223P0300X | DN22812 | FL | Y | Dental Providers | Dentist | Periodontics |
ID Information
| ID | Type | State | Issuer | Description | DN22812 | 01 | FL | DENTAL LICENSE NUMBER | OTHER |