Provider Demographics
NPI:1861604415
Name:MANUEL LA ROSA DDS PS
Entity type:Organization
Organization Name:MANUEL LA ROSA DDS PS
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MANUEL
Authorized Official - Middle Name:J
Authorized Official - Last Name:LA ROSA-CRAIG
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:253-564-1000
Mailing Address - Street 1:1628 S MILDRED ST
Mailing Address - Street 2:SUITE 210
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98465-1627
Mailing Address - Country:US
Mailing Address - Phone:253-564-1000
Mailing Address - Fax:253-564-0102
Practice Address - Street 1:1628 S MILDRED ST
Practice Address - Street 2:SUITE 210
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98465-1627
Practice Address - Country:US
Practice Address - Phone:253-564-1000
Practice Address - Fax:253-564-0102
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-04
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE8413261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental