Provider Demographics
NPI:1750428736
Name:MANELLA, RANDY LEE (DDS)
Entity type:Individual
Prefix:DR
First Name:RANDY
Middle Name:LEE
Last Name:MANELLA
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:541 WABASH AVE NW
Mailing Address - Street 2:
Mailing Address - City:NEW PHILADELPHIA
Mailing Address - State:OH
Mailing Address - Zip Code:44663-4143
Mailing Address - Country:US
Mailing Address - Phone:330-343-2555
Mailing Address - Fax:330-343-2348
Practice Address - Street 1:541 WABASH AVE NW
Practice Address - Street 2:
Practice Address - City:NEW PHILADELPHIA
Practice Address - State:OH
Practice Address - Zip Code:44663-4143
Practice Address - Country:US
Practice Address - Phone:330-343-2555
Practice Address - Fax:330-343-2348
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH300152441223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice