Provider Demographics
NPI:1184638157
Name:MANTIKAS, GEORGE M (DMD)
Entity Type:Individual
Prefix:DR
First Name:GEORGE
Middle Name:M
Last Name:MANTIKAS
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 1:142 E HIGH ST
Mailing Address - Street 2:
Mailing Address - City:EAST HAMPTON
Mailing Address - State:CT
Mailing Address - Zip Code:06424-1543
Mailing Address - Country:US
Mailing Address - Phone:860-267-6666
Mailing Address - Fax:860-267-1854
Practice Address - Street 1:142 E HIGH ST
Practice Address - Street 2:
Practice Address - City:EAST HAMPTON
Practice Address - State:CT
Practice Address - Zip Code:06424-1543
Practice Address - Country:US
Practice Address - Phone:860-267-6666
Practice Address - Fax:860-267-1854
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-28
Last Update Date:2015-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT75361223G0001X
FLDN20762122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist