Healthcare Provider Details

I. General information

NPI: 1669512661
Provider Name (Legal Business Name): MANUEL J LA ROSA DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: MANUEL LA ROSA DDS

II. Dates (important events)

Enumeration Date: 02/07/2007
Last Update Date: 05/09/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1628 S MILDRED ST SUITE 210
TACOMA WA
98465-1627
US

IV. Provider business mailing address

1628 S MILDRED ST SUITE 210
TACOMA WA
98465-1627
US

V. Phone/Fax

Practice location:
  • Phone: 253-564-1000
  • Fax: 253-564-0102
Mailing address:
  • Phone: 253-564-1000
  • Fax: 253-564-0102

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberDE00008413
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: