Provider Demographics
NPI:1750818712
Name:WATANABE, MANA
Entity type:Individual
Prefix:
First Name:MANA
Middle Name:
Last Name:WATANABE
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:PO BOX 291215
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33687-1215
Mailing Address - Country:US
Mailing Address - Phone:786-540-0979
Mailing Address - Fax:
Practice Address - Street 1:12950 RACE TRACK RD STE 109
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33626-1304
Practice Address - Country:US
Practice Address - Phone:813-576-0200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-05-20
Last Update Date:2024-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL243131223G0001X
FL16711223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice