Provider Demographics
NPI:1760931216
Name:MANN, ALYSSA
Entity Type:Individual
Prefix:
First Name:ALYSSA
Middle Name:
Last Name:MANN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:92D MEDICAL GROUP
Mailing Address - Street 2:701 HOSPITAL LOOP SUITE 350
Mailing Address - City:FAIRCHILD AFB
Mailing Address - State:WA
Mailing Address - Zip Code:99011
Mailing Address - Country:US
Mailing Address - Phone:509-247-4329
Mailing Address - Fax:
Practice Address - Street 1:92D MEDICAL GROUP
Practice Address - Street 2:701 HOSPITAL LOOP SUITE 350
Practice Address - City:FAIRCHILD AFB
Practice Address - State:WA
Practice Address - Zip Code:99011
Practice Address - Country:US
Practice Address - Phone:509-247-4329
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-09-26
Last Update Date:2023-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTDEN-DEN-LIC116001223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice