Provider Demographics
NPI:1184850661
Name:DESAI, MANISHA V (DMD)
Entity Type:Individual
Prefix:DR
First Name:MANISHA
Middle Name:V
Last Name:DESAI
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5 N. ROOT ST.
Mailing Address - Street 2:SUITE #105
Mailing Address - City:AURORA
Mailing Address - State:IL
Mailing Address - Zip Code:60505
Mailing Address - Country:US
Mailing Address - Phone:630-800-1137
Mailing Address - Fax:630-800-1672
Practice Address - Street 1:5 N ROOT ST
Practice Address - Street 2:SUITE #105
Practice Address - City:AURORA
Practice Address - State:IL
Practice Address - Zip Code:60505-3429
Practice Address - Country:US
Practice Address - Phone:630-800-1137
Practice Address - Fax:630-800-1672
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-10
Last Update Date:2016-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019.0279691223G0001X, 1223E0200X, 1223X0400X, 1223P0300X, 1223P0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No1223E0200XDental ProvidersDentistEndodontics
No1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics
No1223P0300XDental ProvidersDentistPeriodontics
No1223P0700XDental ProvidersDentistProsthodontics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1184850661Medicaid