Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 122300000X | Dentist | DN22251 | FL |
NPI | 1003361973 |
---|---|
Provider Name | Dr. Theresa Manrique |
First Address | Fort Bragg, NC 28310-0001 |
Second Address | Wesley Chapel, FL 33543-8153 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 22/08/2016 |
Last Update Date | 27/02/2018 |