MEDICARE: MANISH GUPTA D.D.S

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	122300000X	Dentist	30023291	OH

General Provider Information

NPI Number	:	1891007936
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MANISH GUPTA D.D.S

Provider Business Mailing Address
First Line	:	11201 SHAKER BLVD STE 136
Second Line	:
City	:	CLEVELAND
State	:	OH
Zip	:	44104-3833
Country	:	US
Telephone Number	:	216-368-7238
Fax Number	:	217-791-8322

Provider Business Practice Location Address
First Line	:	11201 SHAKER BLVD STE 136
Second Line	:
City	:	CLEVELAND
State	:	OH
Zip	:	44104-3833
Country	:	US
Telephone Number	:	216-368-7238
Fax Number	:	217-791-8322

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/06/2010
Last Update Date	:	07/06/2010

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