Healthcare Provider Details

I. General information

NPI: 1992298228
Provider Name (Legal Business Name): MANALI A VAIDYA DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/12/2018
Last Update Date: 07/01/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4510 EDMONDSON AVE
BALTIMORE MD
21229
US

IV. Provider business mailing address

DENTAL DREAMS LLC, C/O MARINA MILLER 350 N. CLARK STREET, 6TH FLOOR
CHICAGO IL
60654
US

V. Phone/Fax

Practice location:
  • Phone: 410-233-5777
  • Fax:
Mailing address:
  • Phone: 312-274-4524
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number16482
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: