Provider Demographics
NPI:1083788574
Name:ADVANCED DENTAL CARE SERVICES
Entity Type:Organization
Organization Name:ADVANCED DENTAL CARE SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:MAZEN
Authorized Official - Middle Name:
Authorized Official - Last Name:MANLA
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:952-472-1182
Mailing Address - Street 1:2363 COMMERCE BLVD
Mailing Address - Street 2:
Mailing Address - City:MOUND
Mailing Address - State:MN
Mailing Address - Zip Code:55364-1425
Mailing Address - Country:US
Mailing Address - Phone:952-472-1182
Mailing Address - Fax:
Practice Address - Street 1:2363 COMMERCE BLVD
Practice Address - Street 2:
Practice Address - City:MOUND
Practice Address - State:MN
Practice Address - Zip Code:55364-1425
Practice Address - Country:US
Practice Address - Phone:952-472-1182
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-17
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND 118551223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty