Provider Demographics
NPI:1992804595
Name:GARY R MANASSE DMD PA
Entity type:Organization
Organization Name:GARY R MANASSE DMD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:GARY
Authorized Official - Middle Name:R
Authorized Official - Last Name:MANASSE
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:904-646-1414
Mailing Address - Street 1:8708 PERIMETER PARK BLVD
Mailing Address - Street 2:#3
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32216
Mailing Address - Country:US
Mailing Address - Phone:904-646-1414
Mailing Address - Fax:904-646-1454
Practice Address - Street 1:8708 PERIMETER PARK BLVD
Practice Address - Street 2:#3
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32216
Practice Address - Country:US
Practice Address - Phone:904-646-1414
Practice Address - Fax:904-646-1454
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-21
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN134351223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223E0200XDental ProvidersDentistEndodonticsGroup - Single Specialty