Provider Demographics
NPI:1619162070
Name:MANLEY, DANIEL BRUCE (DMD)
Entity Type:Individual
Prefix:DR
First Name:DANIEL
Middle Name:BRUCE
Last Name:MANLEY
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 520
Mailing Address - Street 2:
Mailing Address - City:MT STERLING
Mailing Address - State:KY
Mailing Address - Zip Code:40353-0520
Mailing Address - Country:US
Mailing Address - Phone:859-498-2356
Mailing Address - Fax:859-498-2413
Practice Address - Street 1:1107 INDIAN MOUND DR STE C
Practice Address - Street 2:
Practice Address - City:MT STERLING
Practice Address - State:KY
Practice Address - Zip Code:40353-1300
Practice Address - Country:US
Practice Address - Phone:859-498-2356
Practice Address - Fax:859-498-2413
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-10
Last Update Date:2007-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY5357122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY45003688OtherMEDICAID EPSDT