Healthcare Provider Details

I. General information

NPI: 1750428736
Provider Name (Legal Business Name): RANDY LEE MANELLA D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/31/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

541 WABASH AVE NW
NEW PHILADELPHIA OH
44663-4143
US

IV. Provider business mailing address

541 WABASH AVE NW
NEW PHILADELPHIA OH
44663-4143
US

V. Phone/Fax

Practice location:
  • Phone: 330-343-2555
  • Fax: 330-343-2348
Mailing address:
  • Phone: 330-343-2555
  • Fax: 330-343-2348

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number30015244
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: