Provider Demographics
NPI:1124241575
Name:MANESH, AL SHYSTE (DMD)
Entity type:Individual
Prefix:
First Name:AL
Middle Name:SHYSTE
Last Name:MANESH
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 1:26800 CROWN VALLEY PARKWAY
Mailing Address - Street 2:SUITE 425
Mailing Address - City:MISSION VIEJO
Mailing Address - State:CA
Mailing Address - Zip Code:92691
Mailing Address - Country:US
Mailing Address - Phone:949-364-2935
Mailing Address - Fax:949-364-2870
Practice Address - Street 1:24953 PASEO DE VALENCIA STE 13C
Practice Address - Street 2:
Practice Address - City:LAGUNA HILLS
Practice Address - State:CA
Practice Address - Zip Code:92653-4344
Practice Address - Country:US
Practice Address - Phone:949-600-7123
Practice Address - Fax:949-364-2870
Is Sole Proprietor?:No
Enumeration Date:2007-04-11
Last Update Date:2020-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA48376122300000X, 1223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics
No122300000XDental ProvidersDentist