Provider Demographics
NPI:1407961089
Name:MANOSOV, LEA (DDS)
Entity Type:Individual
Prefix:DR
First Name:LEA
Middle Name:
Last Name:MANOSOV
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2020 COFFEE RD
Mailing Address - Street 2:STE E
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95385-2421
Mailing Address - Country:US
Mailing Address - Phone:209-571-9855
Mailing Address - Fax:209-571-9874
Practice Address - Street 1:2020 COFFEE RD
Practice Address - Street 2:STE E
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95385-2421
Practice Address - Country:US
Practice Address - Phone:209-571-9855
Practice Address - Fax:209-571-9874
Is Sole Proprietor?:No
Enumeration Date:2006-08-21
Last Update Date:2021-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA48326122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist