Provider Demographics
NPI:1104820646
Name:LARA-MURILLO, MANUEL BENJAMIN (DDS)
Entity type:Individual
Prefix:DR
First Name:MANUEL
Middle Name:BENJAMIN
Last Name:LARA-MURILLO
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 1:2887 MYOTIS DR
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95834-2604
Mailing Address - Country:US
Mailing Address - Phone:916-928-6963
Mailing Address - Fax:
Practice Address - Street 1:15515 DALTONS DR
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:CA
Practice Address - Zip Code:95642-9344
Practice Address - Country:US
Practice Address - Phone:209-223-8460
Practice Address - Fax:209-223-8464
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-06-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA44606122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist