Provider Demographics
NPI:1619376787
Name:MANUEL E.MACIAS DDS, A PROFESSIONAL CORP
Entity Type:Organization
Organization Name:MANUEL E.MACIAS DDS, A PROFESSIONAL CORP
Other - Org Name:MANNY E.MACIAS, DDS,INC.
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MANUEL
Authorized Official - Middle Name:EUGENIO
Authorized Official - Last Name:MACIAS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:818-846-2266
Mailing Address - Street 1:2200 W OLIVE AVE
Mailing Address - Street 2:
Mailing Address - City:BURBANK
Mailing Address - State:CA
Mailing Address - Zip Code:91506-2626
Mailing Address - Country:US
Mailing Address - Phone:818-846-2266
Mailing Address - Fax:818-846-2539
Practice Address - Street 1:2200 W OLIVE AVE
Practice Address - Street 2:
Practice Address - City:BURBANK
Practice Address - State:CA
Practice Address - Zip Code:91506-2626
Practice Address - Country:US
Practice Address - Phone:818-846-2266
Practice Address - Fax:818-846-2539
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-08-14
Last Update Date:2014-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA32351122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty