Provider Demographics
NPI:1033324959
Name:MANTI FAMILY DENTAL CLINIC
Entity Type:Organization
Organization Name:MANTI FAMILY DENTAL CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:LEONARD
Authorized Official - Middle Name:R
Authorized Official - Last Name:ASTE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:435-835-4881
Mailing Address - Street 1:93 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MANTI
Mailing Address - State:UT
Mailing Address - Zip Code:84642-1350
Mailing Address - Country:US
Mailing Address - Phone:435-835-4881
Mailing Address - Fax:
Practice Address - Street 1:93 S MAIN ST
Practice Address - Street 2:
Practice Address - City:MANTI
Practice Address - State:UT
Practice Address - Zip Code:84642-1350
Practice Address - Country:US
Practice Address - Phone:435-835-4881
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-14
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT144952-99221223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT529083004011Medicaid