MEDICARE: SPRING & SPROUT MANAL SUNNA, DDS INC.

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	1223P0221X	Pediatric Dentistry

General Provider Information

NPI Number	:	1871283572
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SPRING & SPROUT MANAL SUNNA, DDS INC.

Provider Business Mailing Address
First Line	:	15380 BAGLEY RD
Second Line	:
City	:	MIDDLEBURG HEIGHTS
State	:	OH
Zip	:	44130-4824
Country	:	US
Telephone Number	:	440-568-8920
Fax Number	:

Provider Business Practice Location Address
First Line	:	15380 BAGLEY RD
Second Line	:
City	:	MIDDLEBURG HEIGHTS
State	:	OH
Zip	:	44130-4824
Country	:	US
Telephone Number	:	440-568-8920
Fax Number	:

Authorized Official
Title or Position	:	REVENUE CYCLE MANAGER
Name	:	JENNAFER MARY CORRELL
Credential	:
Telephone Number	:	303-931-3949

Provider Enumeration Date	:	05/08/2023
Last Update Date	:	06/27/2023

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