=====================================================
General NPI Number Information
=====================================================
NPI Number | 1225169683
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SMILES FOR MILES, DENTAL OFFICE OF DR MANOSOV P.C
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/08/2007
-----------------------------------------------------
Last Update Date | 01/22/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2020 COFFEE RD STE E
-----------------------------------------------------
City | MODESTO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95355-2427
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 209-571-9855
-----------------------------------------------------
Fax | 209-571-9874
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2020 COFFEE RD STE E
-----------------------------------------------------
City | MODESTO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95355-2421
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 209-571-9855
-----------------------------------------------------
Fax | 209-571-9874
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | LEA MANOSOV
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 209-571-9855
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 48326
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------