Provider Demographics
NPI:1811100514
Name:MANNE, BRUCE D (DMD)
Entity type:Individual
Prefix:DR
First Name:BRUCE
Middle Name:D
Last Name:MANNE
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:555 W GRANADA BLVD
Mailing Address - Street 2:E2
Mailing Address - City:ORMOND BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32174-9485
Mailing Address - Country:US
Mailing Address - Phone:386-676-0705
Mailing Address - Fax:386-677-9248
Practice Address - Street 1:555 W GRANADA BLVD
Practice Address - Street 2:E2
Practice Address - City:ORMOND BEACH
Practice Address - State:FL
Practice Address - Zip Code:32174-9485
Practice Address - Country:US
Practice Address - Phone:386-676-0705
Practice Address - Fax:386-677-9248
Is Sole Proprietor?:No
Enumeration Date:2007-05-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN 00087061223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL60327OtherBC BS
T94126Medicare UPIN