Provider Demographics
NPI:1518611912
Name:MCMANAMA, SAMUEL PAUL
Entity type:Individual
Prefix:
First Name:SAMUEL
Middle Name:PAUL
Last Name:MCMANAMA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1120 15TH ST # GC5110
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30912-0004
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:13425 HOOVER CREEK BLVD STE 204
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28273-0170
Practice Address - Country:US
Practice Address - Phone:980-999-5007
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-02-05
Last Update Date:2025-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC12855122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist