Provider Demographics
NPI:1538612817
Name:ELILIWI, MANHAL
Entity type:Individual
Prefix:
First Name:MANHAL
Middle Name:
Last Name:ELILIWI
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12752 CEDAR RD
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND HEIGHTS
Mailing Address - State:OH
Mailing Address - Zip Code:44106-3366
Mailing Address - Country:US
Mailing Address - Phone:216-534-0914
Mailing Address - Fax:
Practice Address - Street 1:6564 LOISDALE CT STE 110
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:VA
Practice Address - Zip Code:22150-1822
Practice Address - Country:US
Practice Address - Phone:703-719-5828
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-03
Last Update Date:2021-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA04014173111223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Multi-Specialty