Provider Demographics
NPI:1508905035
Name:MANRIQUE, DIANA CAROLINA (RDH)
Entity Type:Individual
Prefix:MS
First Name:DIANA
Middle Name:CAROLINA
Last Name:MANRIQUE
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5905 SYCAMORE HILL LN
Mailing Address - Street 2:APT. 1214
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28277-4566
Mailing Address - Country:US
Mailing Address - Phone:704-759-8805
Mailing Address - Fax:
Practice Address - Street 1:11535 CARMEL COMMONS BLVD
Practice Address - Street 2:SUITE 200
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28226-5313
Practice Address - Country:US
Practice Address - Phone:704-540-2443
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC7400124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist