Provider Demographics
NPI:1033241104
Name:MANUS, RICHARD C JR (DMD)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:C
Last Name:MANUS
Suffix:JR
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1360 CADUCEUS WAY
Mailing Address - Street 2:BUILDING 500 SUITE 101
Mailing Address - City:WATKINSVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30677
Mailing Address - Country:US
Mailing Address - Phone:706-548-0604
Mailing Address - Fax:706-353-0884
Practice Address - Street 1:1360 CADUCEUS WAY
Practice Address - Street 2:BUILDING 500 SUITE 101
Practice Address - City:WATKINSVILLE
Practice Address - State:GA
Practice Address - Zip Code:30677
Practice Address - Country:US
Practice Address - Phone:706-548-0604
Practice Address - Fax:706-353-0884
Is Sole Proprietor?:No
Enumeration Date:2007-03-12
Last Update Date:2019-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0104121223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA52472462-002OtherBLUE CROSS BLUE SHIELD
GA19NCBWWMedicare ID - Type Unspecified
GA52472462-002OtherBLUE CROSS BLUE SHIELD