Provider Demographics
NPI:1275634917
Name:MANDA, EDWARD A (DDS)
Entity Type:Individual
Prefix:DR
First Name:EDWARD
Middle Name:A
Last Name:MANDA
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:940 E 1264 RD
Mailing Address - Street 2:
Mailing Address - City:LAWRENCE
Mailing Address - State:KS
Mailing Address - Zip Code:66047-9462
Mailing Address - Country:US
Mailing Address - Phone:785-841-1400
Mailing Address - Fax:
Practice Address - Street 1:1425 WAKARUSA DR
Practice Address - Street 2:SUITE A
Practice Address - City:LAWRENCE
Practice Address - State:KS
Practice Address - Zip Code:66049-3832
Practice Address - Country:US
Practice Address - Phone:785-841-1400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-26
Last Update Date:2010-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS56091223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice