Provider Demographics
NPI:1477884641
Name:PRODENT DENTAL LAB
Entity Type:Organization
Organization Name:PRODENT DENTAL LAB
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LAB TECHNICIAN
Authorized Official - Prefix:MR
Authorized Official - First Name:PERCIVAL
Authorized Official - Middle Name:MAGPUSAO
Authorized Official - Last Name:MANZANO
Authorized Official - Suffix:
Authorized Official - Credentials:MDT
Authorized Official - Phone:707-655-8824
Mailing Address - Street 1:3000 ALAMO DR STE 108
Mailing Address - Street 2:
Mailing Address - City:VACAVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95687-6345
Mailing Address - Country:US
Mailing Address - Phone:707-655-8824
Mailing Address - Fax:
Practice Address - Street 1:3000 ALAMO DR STE 108
Practice Address - Street 2:
Practice Address - City:VACAVILLE
Practice Address - State:CA
Practice Address - Zip Code:95687-6345
Practice Address - Country:US
Practice Address - Phone:707-655-8824
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-01-27
Last Update Date:2010-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA016761292200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes292200000XLaboratoriesDental Laboratory