Provider Demographics
NPI:1801280383
Name:MANSKE DENTAL CORPORATION
Entity type:Organization
Organization Name:MANSKE DENTAL CORPORATION
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:JESSICA
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:MANSKE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:424-354-9336
Mailing Address - Street 1:1355 N SIERRA BONITA AVE APT 302
Mailing Address - Street 2:
Mailing Address - City:WEST HOLLYWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:90046-8518
Mailing Address - Country:US
Mailing Address - Phone:424-354-9336
Mailing Address - Fax:424-322-4781
Practice Address - Street 1:445 N ALFRED ST
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90048-2504
Practice Address - Country:US
Practice Address - Phone:424-354-9336
Practice Address - Fax:424-322-4781
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-03-24
Last Update Date:2024-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA59357261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1083926323Medicaid