Provider Demographics
NPI:1720324502
Name:MARIYA MANOVA DMD. P.C.
Entity Type:Organization
Organization Name:MARIYA MANOVA DMD. P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MARIYA
Authorized Official - Middle Name:IVANOVA
Authorized Official - Last Name:MANOVA
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:501-773-1233
Mailing Address - Street 1:502 MAPLE LN
Mailing Address - Street 2:
Mailing Address - City:DARIEN
Mailing Address - State:IL
Mailing Address - Zip Code:60561-4067
Mailing Address - Country:US
Mailing Address - Phone:501-773-1233
Mailing Address - Fax:
Practice Address - Street 1:2746 W FULLERTON AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60647-3059
Practice Address - Country:US
Practice Address - Phone:501-773-1233
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-12-23
Last Update Date:2012-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL060.009921261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental