MEDICARE: MARINA MANOSOV D.D.S.

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	60088	CA

General Provider Information

NPI Number	:	1932402567
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARINA MANOSOV D.D.S.

Provider Business Mailing Address
First Line	:	1180 BLOSSOM HILL RD STE 4
Second Line	:
City	:	SAN JOSE
State	:	CA
Zip	:	95118-3114
Country	:	US
Telephone Number	:	408-978-2500
Fax Number	:

Provider Business Practice Location Address
First Line	:	1180 BLOSSOM HILL RD STE 4
Second Line	:
City	:	SAN JOSE
State	:	CA
Zip	:	95118-3114
Country	:	US
Telephone Number	:	408-978-2500
Fax Number	:

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

Provider Enumeration Date	:	12/21/2010
Last Update Date	:	04/19/2011

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