Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223E0200X | Endodontist | DN13435 | FL |
NPI | 1023351152 |
---|---|
Provider Name | Gary R Manasse |
First Address | Jacksonville, FL 32216 |
Second Address | Jacksonville, FL 32216 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 27/03/2013 |
Last Update Date | 29/03/2013 |