Provider Demographics
NPI:1629761929
Name:MANCIA, AXEL SEBASTIAN BENJAMIN
Entity Type:Individual
Prefix:
First Name:AXEL
Middle Name:SEBASTIAN BENJAMIN
Last Name:MANCIA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6702 NW 112TH AVE
Mailing Address - Street 2:
Mailing Address - City:DORAL
Mailing Address - State:FL
Mailing Address - Zip Code:33178-3713
Mailing Address - Country:US
Mailing Address - Phone:305-562-7033
Mailing Address - Fax:
Practice Address - Street 1:8370 W FLAGLER ST STE 230
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33144-2040
Practice Address - Country:US
Practice Address - Phone:305-562-7033
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-01
Last Update Date:2023-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN279791223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice