Provider Demographics
NPI:1730603382
Name:RAINA, MANSI (DMD)
Entity type:Individual
Prefix:
First Name:MANSI
Middle Name:
Last Name:RAINA
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:651 W BRIAR PL APT 1
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60657-8407
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:561 W DIVERSEY PKWY STE 203
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60614-1682
Practice Address - Country:US
Practice Address - Phone:773-348-3668
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-07-26
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA103924122300000X
IL019031304122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist