Provider Demographics
NPI:1588916852
Name:BRAHMA, MANISHA
Entity type:Individual
Prefix:
First Name:MANISHA
Middle Name:
Last Name:BRAHMA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MANISHA
Other - Middle Name:
Other - Last Name:MALHOTRA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2120 NICOLLET AVE
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55404-2528
Mailing Address - Country:US
Mailing Address - Phone:612-412-3641
Mailing Address - Fax:612-412-3641
Practice Address - Street 1:2120 NICOLLET AVE
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55404-2528
Practice Address - Country:US
Practice Address - Phone:612-412-3641
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-10-10
Last Update Date:2013-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND12337122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1558525204Medicaid
MN1366483802Medicaid