Provider Demographics
NPI:1295703387
Name:PELAEZ, MANUEL NMN (DMD, MS)
Entity type:Individual
Prefix:DR
First Name:MANUEL
Middle Name:NMN
Last Name:PELAEZ
Suffix:
Gender:M
Credentials:DMD, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:USA DENTAC FT STEWART
Mailing Address - Street 2:351 W. 6TH STREET, SUITE 100
Mailing Address - City:FORT STEWART
Mailing Address - State:GA
Mailing Address - Zip Code:31314
Mailing Address - Country:US
Mailing Address - Phone:912-767-8305
Mailing Address - Fax:
Practice Address - Street 1:USA DENTAC FT STEWART
Practice Address - Street 2:351 W. 6TH STREET
Practice Address - City:FORT STEWART
Practice Address - State:GA
Practice Address - Zip Code:31314
Practice Address - Country:US
Practice Address - Phone:912-767-8305
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-14
Last Update Date:2023-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS035547122300000X, 1223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics
No122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
BP8069658OtherFEDERAL DEA