Provider Demographics
NPI:1790830735
Name:MANZELLA, MARTIN JR (DENTIST)
Entity Type:Individual
Prefix:MR
First Name:MARTIN
Middle Name:
Last Name:MANZELLA
Suffix:JR
Gender:M
Credentials:DENTIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1074 EAST AVE
Mailing Address - Street 2:STE U
Mailing Address - City:CHICO
Mailing Address - State:CA
Mailing Address - Zip Code:95926
Mailing Address - Country:US
Mailing Address - Phone:530-342-8580
Mailing Address - Fax:530-342-1456
Practice Address - Street 1:1074 EAST AVE
Practice Address - Street 2:STE U
Practice Address - City:CHICO
Practice Address - State:CA
Practice Address - Zip Code:95926
Practice Address - Country:US
Practice Address - Phone:530-342-8580
Practice Address - Fax:530-342-1456
Is Sole Proprietor?:No
Enumeration Date:2007-01-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA49042122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist