MARIYA MANOVA DMD, P.C. - NPI NUMBER 1669610028

Summary

Provider Name: MARIYA MANOVA DMD, P.C.

NPI Number: 1669610028

Clasification: Dentist (1223G0001X)

Specialization: General Practice

Address:
2759 W 55TH ST
CHICAGO, IL
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
CHICAGO, IL
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

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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
1 NPI 1669610028
2 Entity Type Code 2
3 Employer Identification Number EIN
4 Provider Organization Name Legal Business Name MARIYA MANOVA DMD, P.C.
5 Provider First Line Business Practice Location Address 2759 W 55TH ST
6 Provider Business Practice Location Address City Name CHICAGO
7 Provider Business Practice Location Address State Name IL
8 Provider Business Practice Location Address Postal Code 606322251
9 Provider Business Practice Location Address Country Code If outside U S US
10 Provider Business Practice Location Address Telephone Number 5017731233
11 Provider Enumeration Date 1/22/2009
12 Last Update Date 1/22/2009
13 Authorized Official Last Name MANOVA
14 Authorized Official First Name MARIYA
15 Authorized Official Middle Name I
16 Authorized Official Title or Position PRESIDENT
17 Authorized Official Telephone Number 5017731233
18 Healthcare Provider Taxonomy Code 1 1223G0001X
19 Provider License Number 1 019027529
20 Provider License Number State Code 1 IL
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: 8/12/2014
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