Healthcare Provider Details

I. General information

NPI: 1902952070
Provider Name (Legal Business Name): RENALIE MANUEL DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: RENALIE REBONG DDS

II. Dates (important events)

Enumeration Date: 01/25/2007
Last Update Date: 06/27/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

169 N NELLIS BLVD
LAS VEGAS NV
89110-5320
US

IV. Provider business mailing address

526 S TONOPAH DR STE. 200
LAS VEGAS NV
89106-4043
US

V. Phone/Fax

Practice location:
  • Phone: 702-384-1010
  • Fax: 702-438-8424
Mailing address:
  • Phone: 702-291-2031
  • Fax: 702-366-1483

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number55087
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number5176
License Number StateNV
# 3
Primary TaxonomyN
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number5176
License Number StateNV
# 4
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License NumberS6-108
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: