MEDICARE: MARIYA MANOVA DMD, P.C.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	019027529	IL

General Provider Information

NPI Number	:	1669610028
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MARIYA MANOVA DMD, P.C.

Provider Business Mailing Address
First Line	:	215 W 59TH ST APT 20
Second Line	:
City	:	HINSDALE
State	:	IL
Zip	:	60521-4928
Country	:	US
Telephone Number	:	501-773-1233
Fax Number	:

Provider Business Practice Location Address
First Line	:	2759 W 55TH ST
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60632-2251
Country	:	US
Telephone Number	:	501-773-1233
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. MARIYA I MANOVA
Credential	:	DMD
Telephone Number	:	501-773-1233

Provider Enumeration Date	:	01/22/2009
Last Update Date	:	01/22/2009

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