Provider Demographics
NPI:1114309085
Name:MANTAS, SELISSA (DMD)
Entity Type:Individual
Prefix:
First Name:SELISSA
Middle Name:
Last Name:MANTAS
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 1:2930 11TH AVE
Mailing Address - Street 2:
Mailing Address - City:EVANS
Mailing Address - State:CO
Mailing Address - Zip Code:80620-1011
Mailing Address - Country:US
Mailing Address - Phone:970-350-4606
Mailing Address - Fax:970-350-4645
Practice Address - Street 1:302 3RD ST SE STE 150
Practice Address - Street 2:
Practice Address - City:LOVELAND
Practice Address - State:CO
Practice Address - Zip Code:80537
Practice Address - Country:US
Practice Address - Phone:970-461-8942
Practice Address - Fax:970-292-1538
Is Sole Proprietor?:No
Enumeration Date:2015-06-26
Last Update Date:2018-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1001107-151223G0001X
CO2036021223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice