Provider Demographics
NPI:1750884680
Name:MANLEY, RAQUEL NICOLE (DMD)
Entity type:Individual
Prefix:DR
First Name:RAQUEL
Middle Name:NICOLE
Last Name:MANLEY
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6 CENTER ST
Mailing Address - Street 2:
Mailing Address - City:TARIFFVILLE
Mailing Address - State:CT
Mailing Address - Zip Code:06081-9662
Mailing Address - Country:US
Mailing Address - Phone:339-224-1100
Mailing Address - Fax:
Practice Address - Street 1:98 WEST ST
Practice Address - Street 2:
Practice Address - City:LITCHFIELD
Practice Address - State:CT
Practice Address - Zip Code:06759-3500
Practice Address - Country:US
Practice Address - Phone:860-567-8684
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-16
Last Update Date:2020-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT12207390200000X
CT12727122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program