Provider Demographics
NPI:1174879449
Name:MANALASTAS, JUSTINE CALAZAN (DMD)
Entity type:Individual
Prefix:
First Name:JUSTINE
Middle Name:CALAZAN
Last Name:MANALASTAS
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5504 E 22ND ST STE 140
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85711-5586
Mailing Address - Country:US
Mailing Address - Phone:520-777-0790
Mailing Address - Fax:
Practice Address - Street 1:5504 E 22ND ST STE 140
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85711-5586
Practice Address - Country:US
Practice Address - Phone:520-777-0790
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-07-24
Last Update Date:2012-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZD008502122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist