Provider Demographics
NPI:1447324926
Name:MANLA, MAZEN (DDS)
Entity type:Individual
Prefix:DR
First Name:MAZEN
Middle Name:
Last Name:MANLA
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2363 COMMERCE BLVD
Mailing Address - Street 2:
Mailing Address - City:MOUND
Mailing Address - State:MN
Mailing Address - Zip Code:55364-1425
Mailing Address - Country:US
Mailing Address - Phone:952-472-1182
Mailing Address - Fax:
Practice Address - Street 1:2363 COMMERCE BLVD
Practice Address - Street 2:
Practice Address - City:MOUND
Practice Address - State:MN
Practice Address - Zip Code:55364-1425
Practice Address - Country:US
Practice Address - Phone:952-472-1182
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND 118551223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice