=====================================================
General NPI Number Information
=====================================================
NPI Number | 1629084165
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SADANAND MANOLI DDS
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/01/2006
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1559 WEST GREENFIELD AVE
-----------------------------------------------------
City | MILWAUKEE
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53204
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 414-383-1034
-----------------------------------------------------
Fax | 414-463-9100
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1559 WEST GREENFIELD AVE
-----------------------------------------------------
City | MILWAUKEE
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53204
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 414-383-1034
-----------------------------------------------------
Fax | 414-463-9100
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223P0700X
-----------------------------------------------------
Taxonomy Name | Prosthodontics
-----------------------------------------------------
License Number | 5001575015
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------