Provider Demographics
NPI:1205454469
Name:UTREJA, MANITA GROVER (DMD)
Entity type:Individual
Prefix:DR
First Name:MANITA
Middle Name:GROVER
Last Name:UTREJA
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:DR
Other - First Name:MANITA
Other - Middle Name:
Other - Last Name:GROVER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DMD
Mailing Address - Street 1:2800 COLLEGE AVENUE
Mailing Address - Street 2:
Mailing Address - City:ALTON
Mailing Address - State:IL
Mailing Address - Zip Code:62002
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:148 NORTHBAY CT
Practice Address - Street 2:
Practice Address - City:GLEN CARBON
Practice Address - State:IL
Practice Address - Zip Code:62034-2994
Practice Address - Country:US
Practice Address - Phone:317-693-9801
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-13
Last Update Date:2024-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019032707122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist