Provider Demographics
NPI:1669512661
Name:LA ROSA, MANUEL J (DDS)
Entity type:Individual
Prefix:DR
First Name:MANUEL
Middle Name:J
Last Name:LA ROSA
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:DR
Other - First Name:MANUEL
Other - Middle Name:
Other - Last Name:LA ROSA
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DDS
Mailing Address - Street 1:1628 S MILDRED ST
Mailing Address - Street 2:SUITE 210
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98465-1627
Mailing Address - Country:US
Mailing Address - Phone:253-564-1000
Mailing Address - Fax:253-564-0102
Practice Address - Street 1:1628 S MILDRED ST
Practice Address - Street 2:SUITE 210
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98465-1627
Practice Address - Country:US
Practice Address - Phone:253-564-1000
Practice Address - Fax:253-564-0102
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-07
Last Update Date:2016-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE000084131223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery