Basic Information
| Provider Information | |||||||||
| NPI: | 1295703387 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PELAEZ | ||||||||
| FirstName: | MANUEL | ||||||||
| MiddleName: | -NMN | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DMD | ||||||||
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| Mailing Information | |||||||||
| Address1: | USA DENTAC FT GORDON | ||||||||
| Address2: | 38TH STREET BLDG 38717 | ||||||||
| City: | FORT GORDON | ||||||||
| State: | GA | ||||||||
| PostalCode: | 309055660 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7067876927 | ||||||||
| FaxNumber: | 7067872081 | ||||||||
| Practice Location | |||||||||
| Address1: | USA DENTAC FT GORDON | ||||||||
| Address2: | 38TH STREET BLDG 38717 | ||||||||
| City: | FORT GORDON | ||||||||
| State: | GA | ||||||||
| PostalCode: | 309055660 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7067876927 | ||||||||
| FaxNumber: | 7067872081 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/14/2006 | ||||||||
| LastUpdateDate: | 05/28/2010 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X | DS035547 | PA | Y | Dental Providers | Dentist |
ID Information
| ID | Type | State | Issuer | Description | BP8069658 | 01 | FEDERAL DEA | OTHER |