Provider Name: MARIYA MANOVA DMD, P.C.

NPI Number: 1669610028

Clasification: Dentist (1223G0001X)

Specialization: General Practice

2759 W 55TH ST
ZIP 60632

Phone Number: (501) 773-1233

Detailed Information

MARIYA MANOVA DMD, P.C. is a general practice dentist in Chicago, IL. The provider is a general dentist is the primary dental care provider for patients of all ages. The general dentist is responsible for the diagnosis, treatment, management and overall coordination of services related to patients' oral health needs. The assigned NPI number for this provider is 1669610028 and is registered as an organization entity type and is a single specialty group.

The provider's business address is:

2759 W 55TH ST
ZIP 60632-251
Phone: (501) 773-1233

The provider's authorized official is Mariya I Manova .
The authorized official title is President and has the following contact phone number (501) 773-1233.

The enumeration date for this NPI number is 1/22/2009 and was last updated on 1/22/2009.

Map - Location of Practice

Taxonomy Codes

The following information regarding the scope of practice of this provider is available:

No. Taxonomy Code Taxonomy Clasification Taxonomy Specialization License Number License State Primary
1 1223G0001X Dentist General Practice 019027529 IL Yes

NPI Record

No. Field Name Field Value Field Definition 1
1 NPI 1669610028 The 10-position all-numeric identification number assigned by the NPS to uniquely identify a health care provider. The NPI number includes an ISO standard check-digit in the 10th position. There is no intelligence about the health care provider in the number.
2 Entity Type Code 2 Code describing the type of health care provider that is being assigned an NPI. Codes are 1 = (Person): individual human being who furnishes health care; 2 = (Non-person): entity other than an individual human being that furnishes health care (for example, hospital, SNF, hospital subunit, pharmacy, or HMO).
3 Employer Identification Number EIN The Employer Identification Number (EIN), assigned by the IRS, of the provider being identified.
4 Provider Organization Name Legal Business Name MARIYA MANOVA DMD, P.C. The name of the organization provider. If the provider is an organization, this is the legal business name.
5 Provider First Line Business Practice Location Address 2759 W 55TH ST The first line location address of the provider being identified. For providers with more than one physical location, this is the primary location. This address cannot include a Post Office box.
6 Provider Business Practice Location Address City Name CHICAGO The city name in the location address of the provider being identified.
7 Provider Business Practice Location Address State Name IL The State code in the location of the provider being identified.
8 Provider Business Practice Location Address Postal Code 606322251 The postal ZIP or zone code in the location address of the provider being identified. NOTE: ZIP code plus 4-digit extension, if available.
9 Provider Business Practice Location Address Country Code If outside U S US The country code in the location address of the provider being identified.
10 Provider Business Practice Location Address Telephone Number 5017731233 The telephone number associated with the location address of the provider being identified.
11 Provider Enumeration Date 1/22/2009 The date the provider was assigned a unique identifier (assigned an NPI).
12 Last Update Date 1/22/2009 The date that a record was last updated or changed.
13 Authorized Official Last Name MANOVA The last name of the person authorized to submit the NPI application or to change NPS data for a health care provider.
14 Authorized Official First Name MARIYA The first name of the authorized official.
15 Authorized Official Middle Name I The middle name of the authorized official.
16 Authorized Official Title or Position PRESIDENT The title or position of the authorized official.
17 Authorized Official Telephone Number 5017731233 The 10-position telephone number of the authorized official.
18 Healthcare Provider Taxonomy Code 1 1223G0001X Code designating the provider type, classification, and specialization. Codes are from the Healthcare Provider Taxonomy code list. The NPS will associate these data with the license data for providers with Entity type code = 1.
19 Provider License Number 1 019027529 The license number issued to the provider being identified. The NPS can accommodate multiple license numbers for multiple specialties and for multiple States. The NPS will associate this data element with ‘‘provider taxonomy code’’.
20 Provider License Number State Code 1 IL The code representing the State that issued the license to the provider being identified. This field can accommodate multiple States. It is associated with ‘‘provider license number.
21 Healthcare Provider Primary Taxonomy Switch 1 Y
22 Is Organization Subpart N
23 Authorized Official Name Prefix Text DR.
24 Authorized Official Credential Text DMD
25 Healthcare Provider Taxonomy Group 1 193400000X SINGLE SPECIALTY GROUP

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This page was last updated on: 4/19/2015

(1) Field Definition Source-. Federal Register / Vol. 69, No. 15 / Friday, January 23, 2004 / Rules and Regulations - Part II Department of Health and Human Services Office of the Secretary 45 CFR Part 162 HIPAA Administrative Simplification: Standard Unique Health Identifier for Health Care Providers; Final Rule

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