Provider Demographics
NPI:1730312760
Name:MANIBO, LOURDES ALEXANDRA (DDS)
Entity Type:Individual
Prefix:DR
First Name:LOURDES
Middle Name:ALEXANDRA
Last Name:MANIBO
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:DR
Other - First Name:LOURDES
Other - Middle Name:ALEXANDRA
Other - Last Name:MANIBO
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DDS
Mailing Address - Street 1:4800 LAKEWOOD RANCH BLVD
Mailing Address - Street 2:
Mailing Address - City:BRADENTON
Mailing Address - State:FL
Mailing Address - Zip Code:34211-4953
Mailing Address - Country:US
Mailing Address - Phone:941-405-1600
Mailing Address - Fax:
Practice Address - Street 1:4800 LAKEWOOD RANCH BLVD
Practice Address - Street 2:
Practice Address - City:BRADENTON
Practice Address - State:FL
Practice Address - Zip Code:34211-4953
Practice Address - Country:US
Practice Address - Phone:941-405-1600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-08-25
Last Update Date:2021-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN193871223G0001X
NY0545311223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice