Provider Demographics
NPI:1972385714
Name:MANOSOV, MORAN
Entity type:Individual
Prefix:
First Name:MORAN
Middle Name:
Last Name:MANOSOV
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2619 AURORA ASTORGA DR
Mailing Address - Street 2:
Mailing Address - City:TRACY
Mailing Address - State:CA
Mailing Address - Zip Code:95376-8202
Mailing Address - Country:US
Mailing Address - Phone:408-857-9046
Mailing Address - Fax:
Practice Address - Street 1:2020 COFFEE RD STE E1
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95355-2421
Practice Address - Country:US
Practice Address - Phone:209-571-9855
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-10-17
Last Update Date:2023-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1095991223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice