Healthcare Provider Details

I. General information

NPI: 1497404917
Provider Name (Legal Business Name): MEHTAB MANJI
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/22/2022
Last Update Date: 10/08/2023
Certification Date: 10/08/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6292 LAWRENCEVILLE HWY
TUCKER GA
30084-1870
US

IV. Provider business mailing address

2914 SILVERMERE LN
DULUTH GA
30097-4324
US

V. Phone/Fax

Practice location:
  • Phone: 551-996-5635
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDN123245
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: