Basic Information
| Provider Information | |||||||||
| NPI: | 1043777501 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | AVILA | ||||||||
| FirstName: | MANUELA | ||||||||
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| Credential: | DDS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 117 W 20TH ST APT 409 | ||||||||
| Address2: | |||||||||
| City: | KANSAS CITY | ||||||||
| State: | MO | ||||||||
| PostalCode: | 641082080 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9154975338 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1205 NE CORONADO DR | ||||||||
| Address2: | |||||||||
| City: | BLUE SPRINGS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 640142928 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8162284090 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/20/2019 | ||||||||
| LastUpdateDate: | 02/20/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | 2018043082 | MO | Y | Dental Providers | Dentist | General Practice |
No ID Information.