=====================================================
General NPI Number Information
=====================================================
NPI Number | 1922658178
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | NATALIE MANN DDS
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/18/2019
-----------------------------------------------------
Last Update Date | 09/18/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 405 W FOOTHILL BLVD STE 104
-----------------------------------------------------
City | CLAREMONT
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91711-2799
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 909-626-1236
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6021 FOUNTAIN PARK LN APT 7
-----------------------------------------------------
City | WOODLAND HILLS
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91367-3523
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 818-455-1936
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 104185
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------