Healthcare Provider Details

I. General information

NPI: 1568156735
Provider Name (Legal Business Name): AJITH RENGARAJAN MANIPALA DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/08/2023
Last Update Date: 12/18/2025
Certification Date: 12/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

32280 FIVE MILE RD
LIVONIA MI
48154-6112
US

IV. Provider business mailing address

4151 17 MILE RD STE F
STERLING HEIGHTS MI
48310-6866
US

V. Phone/Fax

Practice location:
  • Phone: 734-425-7010
  • Fax:
Mailing address:
  • Phone: 586-979-3200
  • Fax: 586-979-3226

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number2901601769
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: