Provider Demographics
NPI:1568813459
Name:VIRDI, MANISHA (DDS)
Entity Type:Individual
Prefix:
First Name:MANISHA
Middle Name:
Last Name:VIRDI
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:850 36TH AVE
Mailing Address - Street 2:
Mailing Address - City:MOLINE
Mailing Address - State:IL
Mailing Address - Zip Code:61265-7169
Mailing Address - Country:US
Mailing Address - Phone:309-764-7631
Mailing Address - Fax:309-764-7635
Practice Address - Street 1:850 36TH AVE
Practice Address - Street 2:
Practice Address - City:MOLINE
Practice Address - State:IL
Practice Address - Zip Code:61265-7169
Practice Address - Country:US
Practice Address - Phone:309-764-7631
Practice Address - Fax:309-764-7635
Is Sole Proprietor?:No
Enumeration Date:2016-06-22
Last Update Date:2022-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019-0307301223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA1598759292Medicaid
ILPENDINGMedicaid