Provider Demographics
NPI:1528459559
Name:PALAU, MANUEL JOSE
Entity type:Individual
Prefix:
First Name:MANUEL
Middle Name:JOSE
Last Name:PALAU
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 1:18943 VICKIE AVE. APT 51
Mailing Address - Street 2:
Mailing Address - City:CERRITOS
Mailing Address - State:CA
Mailing Address - Zip Code:90703
Mailing Address - Country:US
Mailing Address - Phone:949-394-2499
Mailing Address - Fax:
Practice Address - Street 1:14435 HAMLIN ST. SUITE 208
Practice Address - Street 2:
Practice Address - City:VAN NUYS
Practice Address - State:CA
Practice Address - Zip Code:91401
Practice Address - Country:US
Practice Address - Phone:818-988-7067
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-02-12
Last Update Date:2015-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA63865122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist