Provider Demographics
NPI:1245795640
Name:MANLEY, LORA
Entity Type:Individual
Prefix:
First Name:LORA
Middle Name:
Last Name:MANLEY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:340 W LOGAN ST
Mailing Address - Street 2:
Mailing Address - City:NOBLESVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46060-1432
Mailing Address - Country:US
Mailing Address - Phone:317-776-0105
Mailing Address - Fax:
Practice Address - Street 1:340 W LOGAN ST
Practice Address - Street 2:
Practice Address - City:NOBLESVILLE
Practice Address - State:IN
Practice Address - Zip Code:46060-1432
Practice Address - Country:US
Practice Address - Phone:317-776-0105
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-02-10
Last Update Date:2023-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
IN12013963A1223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program