Provider Demographics
NPI:1144745472
Name:MANZELLA, KEVIN SCOTT (DDS, MS)
Entity Type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:SCOTT
Last Name:MANZELLA
Suffix:
Gender:M
Credentials:DDS, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:327 EUCLID AVE
Mailing Address - Street 2:
Mailing Address - City:KENMORE
Mailing Address - State:NY
Mailing Address - Zip Code:14217-2903
Mailing Address - Country:US
Mailing Address - Phone:716-785-4684
Mailing Address - Fax:
Practice Address - Street 1:4306 SENECA ST
Practice Address - Street 2:
Practice Address - City:WEST SENECA
Practice Address - State:NY
Practice Address - Zip Code:14224-3169
Practice Address - Country:US
Practice Address - Phone:716-337-5066
Practice Address - Fax:716-677-5413
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-08
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY059107-1122300000X, 1223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics
No122300000XDental ProvidersDentist