MEDICARE: DR. BERNIE SAMPANG MANASAN DDS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	0401410997	VA
2	1223G0001X	General Practice Dentistry	DN012534	GA

General Provider Information

NPI Number	:	1679549430
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. BERNIE SAMPANG MANASAN DDS

Provider Business Mailing Address
First Line	:	2463 CALLE AGUADULCE
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92139-2238
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2463 CALLE AGUADULCE
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92139-2238
Country	:	US
Telephone Number	:	760-220-4885
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/23/2006
Last Update Date	:	08/14/2019

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