Provider Demographics
NPI:1114381506
Name:MANZI, MATTHEW JAMES (DMD)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:JAMES
Last Name:MANZI
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:62 QUEENSBERRY ST
Mailing Address - Street 2:#107
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02215-5180
Mailing Address - Country:US
Mailing Address - Phone:617-817-8242
Mailing Address - Fax:
Practice Address - Street 1:62 QUEENSBERRY ST
Practice Address - Street 2:#107
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02215-5180
Practice Address - Country:US
Practice Address - Phone:617-817-8242
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-11
Last Update Date:2016-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MADN18573381223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice