=====================================================
General NPI Number Information
=====================================================
NPI Number | 1457449357
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GARY M MCMANAMA DDS PA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/10/2006
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1621 N PLAZA DR
-----------------------------------------------------
City | TALLAHASSEE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32308
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 850-878-5186
-----------------------------------------------------
Fax | 850-942-9428
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1621 N PLAZA DR
-----------------------------------------------------
City | TALLAHASSEE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32308
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 850-878-5186
-----------------------------------------------------
Fax | 850-942-9428
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. GARY MICHAEL MCMANAMA
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 850-787-5186
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | DN6222
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------