Provider Demographics
NPI:1275770596
Name:AMANA DENTAL CORP.
Entity Type:Organization
Organization Name:AMANA DENTAL CORP.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESEDENT
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:312-451-4050
Mailing Address - Street 1:2326 CENTRAL AVE NE
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55418-3710
Mailing Address - Country:US
Mailing Address - Phone:612-789-2928
Mailing Address - Fax:612-789-2783
Practice Address - Street 1:2326 CENTRAL AVE NE
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55418-3710
Practice Address - Country:US
Practice Address - Phone:612-789-2928
Practice Address - Fax:612-789-2783
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-01-08
Last Update Date:2009-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND 118551223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN330405100Medicaid