Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223S0112X | Oral and Maxillofacial Surgeon | 010412 | GA |
NPI | 1033241104 |
---|---|
Provider Name | Dr. Richard C Manus JR. |
First Address | Watkinsville, GA 30677 |
Second Address | Watkinsville, GA 30677 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 12/03/2007 |
Last Update Date | 15/05/2019 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
52472462-002 | BLUE CROSS BLUE SHIELD (01) | GA |
U77627 | (02) | GA |