MEDICARE: DR. MARIYA IVANOVA MANOVA 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	019027529	IL

General Provider Information

NPI Number	:	1427239516
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MARIYA IVANOVA MANOVA DMD

Provider Business Mailing Address
First Line	:	502 MAPLE LN
Second Line	:
City	:	DARIEN
State	:	IL
Zip	:	60561-4067
Country	:	US
Telephone Number	:	501-773-1233
Fax Number	:

Provider Business Practice Location Address
First Line	:	2746 W FULLERTON AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60647-3059
Country	:	US
Telephone Number	:	501-773-1233
Fax Number	:

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

Provider Enumeration Date	:	11/17/2007
Last Update Date	:	12/23/2012

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