Provider Demographics
NPI:1467661249
Name:MANN, JUDY ANN (RDHAP)
Entity Type:Individual
Prefix:MRS
First Name:JUDY
Middle Name:ANN
Last Name:MANN
Suffix:
Gender:F
Credentials:RDHAP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3074 BURGAN AVE
Mailing Address - Street 2:
Mailing Address - City:CLOVIS
Mailing Address - State:CA
Mailing Address - Zip Code:93611-5231
Mailing Address - Country:US
Mailing Address - Phone:559-292-2762
Mailing Address - Fax:559-292-2762
Practice Address - Street 1:3074 BURGAN AVE
Practice Address - Street 2:
Practice Address - City:CLOVIS
Practice Address - State:CA
Practice Address - Zip Code:93611-5231
Practice Address - Country:US
Practice Address - Phone:559-292-2762
Practice Address - Fax:559-292-2762
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA#59124Q00000X
CA17916124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAH-0005901OtherDENTI- CAL
CA17916OtherRDH LICENSE