Provider Demographics
NPI:1902952070
Name:MANUEL, RENALIE (DDS)
Entity Type:Individual
Prefix:DR
First Name:RENALIE
Middle Name:
Last Name:MANUEL
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:RENALIE
Other - Middle Name:
Other - Last Name:REBONG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DDS
Mailing Address - Street 1:526 S TONOPAH DR
Mailing Address - Street 2:STE. 200
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89106-4043
Mailing Address - Country:US
Mailing Address - Phone:702-291-2031
Mailing Address - Fax:702-366-1483
Practice Address - Street 1:169 N NELLIS BLVD
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89110-5320
Practice Address - Country:US
Practice Address - Phone:702-384-1010
Practice Address - Fax:702-438-8424
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-25
Last Update Date:2016-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA550871223G0001X
NV51761223G0001X, 1223P0221X
NVS6-1081223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
No1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV1902952070Medicaid