Healthcare Provider Details

I. General information

NPI: 1104820646
Provider Name (Legal Business Name): MANUEL BENJAMIN LARA-MURILLO DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 06/13/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15515 DALTONS DR
JACKSON CA
95642-9344
US

IV. Provider business mailing address

2887 MYOTIS DR
SACRAMENTO CA
95834-2604
US

V. Phone/Fax

Practice location:
  • Phone: 209-223-8460
  • Fax: 209-223-8464
Mailing address:
  • Phone: 916-928-6963
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number44606
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: