MEDICARE: MANAL TABBA DMD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	122300000X	Dentist	019033352	IL

General Provider Information

NPI Number	:	1184392573
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MANAL TABBA DMD

Provider Business Mailing Address
First Line	:	50 YORKTOWN CTR UNIT 160
Second Line	:
City	:	LOMBARD
State	:	IL
Zip	:	60148-5580
Country	:	US
Telephone Number	:	678-425-7088
Fax Number	:

Provider Business Practice Location Address
First Line	:	148 E ARMY TRAIL RD
Second Line	:
City	:	GLENDALE HEIGHTS
State	:	IL
Zip	:	60139-1647
Country	:	US
Telephone Number	:	224-698-1472
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/01/2021
Last Update Date	:	06/06/2023

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