Healthcare Provider Details

I. General information

NPI: 1548164353
Provider Name (Legal Business Name): IVANNA NICOLE RIOS MANRIQUEZ DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/05/2026
Last Update Date: 10/05/2026
Certification Date: 10/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

42505 WASHINGTON ST STE 101
PALM DESERT CA
92211-8835
US

IV. Provider business mailing address

482 W SAN YSIDRO BLVD STE 1030
SAN YSIDRO CA
92173-2444
US

V. Phone/Fax

Practice location:
  • Phone: 760-342-4341
  • Fax:
Mailing address:
  • Phone: 442-370-4785
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number112988
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: