Healthcare Provider Details

I. General information

NPI: 1639004906
Provider Name (Legal Business Name): DR. RAJESWARI MANAM
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/16/2026
Last Update Date: 10/02/2026
Certification Date: 10/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6215 E STATE ST
ROCKFORD IL
61108-2514
US

IV. Provider business mailing address

6349 GALLEON DR
MECHANICSBURG PA
17050-2949
US

V. Phone/Fax

Practice location:
  • Phone: 815-399-7777
  • Fax:
Mailing address:
  • Phone: 562-481-4696
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number019.037481
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: