Provider Demographics
NPI:1568156735
Name:MANIPALA, AJITH RENGARAJAN (DDS)
Entity type:Individual
Prefix:DR
First Name:AJITH
Middle Name:RENGARAJAN
Last Name:MANIPALA
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4151 17 MILE RD STE F
Mailing Address - Street 2:
Mailing Address - City:STERLING HEIGHTS
Mailing Address - State:MI
Mailing Address - Zip Code:48310-6866
Mailing Address - Country:US
Mailing Address - Phone:586-979-3200
Mailing Address - Fax:586-979-3226
Practice Address - Street 1:30003 SOUTHFIELD RD
Practice Address - Street 2:
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48076-1433
Practice Address - Country:US
Practice Address - Phone:248-646-2273
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-08
Last Update Date:2024-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2901601769122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist