Basic Information
| Provider Information | |||||||||
| NPI: | 1871636845 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MAMANI | ||||||||
| FirstName: | CESAR | ||||||||
| MiddleName: | |||||||||
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| Credential: | DDS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1328 S MISSION RD | ||||||||
| Address2: | |||||||||
| City: | FALLBROOK | ||||||||
| State: | CA | ||||||||
| PostalCode: | 920284006 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7604512730 | ||||||||
| FaxNumber: | 7604512700 | ||||||||
| Practice Location | |||||||||
| Address1: | 22675 ALESSANDRO BLVD | ||||||||
| Address2: | |||||||||
| City: | MORENO VALLEY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 925538551 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9515712300 | ||||||||
| FaxNumber: | 9515712330 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/15/2007 | ||||||||
| LastUpdateDate: | 01/13/2012 | ||||||||
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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 | 1223G0001X | 52428 | CA | Y | Dental Providers | Dentist | General Practice |
ID Information
| ID | Type | State | Issuer | Description | HAP70275G | 01 | CA | PACT | OTHER | FHC70275G | 01 | CO | MEDI-CAL | OTHER |