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General NPI Number Information
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NPI Number | 1669610028
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Entity Type | Organization
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Legal Business Name | MARIYA MANOVA DMD, P.C.
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Dates
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Enumeration Date | 01/22/2009
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Last Update Date | 01/22/2009
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Provider Practice Location Address
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Address Line | 2759 W 55TH ST
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City | CHICAGO
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State | IL
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Zip | 60632-2251
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Country | US
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Telephone | 501-773-1233
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Fax |
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Provider Business Mailing Address
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Address Line | 215 W 59TH ST APT 20
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City | HINSDALE
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State | IL
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Zip | 60521-4928
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Country | US
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Telephone | 501-773-1233
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. MARIYA I MANOVA
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Credential | DMD
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Telephone | 501-773-1233
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | 019027529
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License Number State | IL
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