=====================================================
General NPI Number Information
=====================================================
NPI Number | 1003361973
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | THERESA MANRIQUE DMD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/22/2016
-----------------------------------------------------
Last Update Date | 02/27/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 31806 BLYTHEWOOD WAY
-----------------------------------------------------
City | WESLEY CHAPEL
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33543-8153
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 813-325-1153
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | ARDENNES ROAD
-----------------------------------------------------
City | FORT BRAGG
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28310-0001
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | DN22251
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------