Healthcare Provider Details

I. General information

NPI: 1740980077
Provider Name (Legal Business Name): BIANCA MANISCALCO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/06/2023
Last Update Date: 08/28/2024
Certification Date: 08/28/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2821 GRAND AVE
WAUKEGAN IL
60085-2372
US

IV. Provider business mailing address

761 HARRISON AVE APT 407
BOSTON MA
02118-3478
US

V. Phone/Fax

Practice location:
  • Phone: 847-662-4400
  • Fax:
Mailing address:
  • Phone: 630-450-6391
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number019.035496
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number390200000X
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: