Provider Demographics
NPI:1245584218
Name:FAMILY DENTISTRY MARINA MANOSOV DDS INC
Entity Type:Organization
Organization Name:FAMILY DENTISTRY MARINA MANOSOV DDS INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARINA
Authorized Official - Middle Name:
Authorized Official - Last Name:MANOSOV
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:650-383-5599
Mailing Address - Street 1:4646 EL CAMINO REAL
Mailing Address - Street 2:
Mailing Address - City:LOS ALTOS
Mailing Address - State:CA
Mailing Address - Zip Code:94022-1329
Mailing Address - Country:US
Mailing Address - Phone:650-383-5599
Mailing Address - Fax:
Practice Address - Street 1:4646 EL CAMINO REAL
Practice Address - Street 2:
Practice Address - City:LOS ALTOS
Practice Address - State:CA
Practice Address - Zip Code:94022-1329
Practice Address - Country:US
Practice Address - Phone:650-383-5599
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-10-30
Last Update Date:2012-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty