Provider Demographics
NPI:1427742287
Name:PEREZ, MANUEL
Entity type:Individual
Prefix:
First Name:MANUEL
Middle Name:
Last Name:PEREZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1051 E STUART DR
Mailing Address - Street 2:
Mailing Address - City:GALAX
Mailing Address - State:VA
Mailing Address - Zip Code:24333-2520
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1202 N MAIN ST
Practice Address - Street 2:
Practice Address - City:HILLSVILLE
Practice Address - State:VA
Practice Address - Zip Code:24343-1133
Practice Address - Country:US
Practice Address - Phone:276-728-5899
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-05
Last Update Date:2023-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0401418479122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist