Provider Demographics
NPI:1598087439
Name:ILIJIC MANZANERA, DINA MIREYA (RDH)
Entity Type:Individual
Prefix:
First Name:DINA
Middle Name:MIREYA
Last Name:ILIJIC MANZANERA
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 1:1601 FRUITVALE AVE
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94601-2418
Mailing Address - Country:US
Mailing Address - Phone:510-535-4000
Mailing Address - Fax:510-535-4128
Practice Address - Street 1:3050 E 16TH ST
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94601-2319
Practice Address - Country:US
Practice Address - Phone:510-535-4000
Practice Address - Fax:510-535-4128
Is Sole Proprietor?:No
Enumeration Date:2010-02-19
Last Update Date:2010-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARDH24464124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist