Provider Demographics
NPI:1235422999
Name:MANCEWICZ, STEPHEN MICHAEL (DDS)
Entity Type:Individual
Prefix:MR
First Name:STEPHEN
Middle Name:MICHAEL
Last Name:MANCEWICZ
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2351 COUNTRYWOOD DR SE
Mailing Address - Street 2:SUITE B
Mailing Address - City:KENTWOOD
Mailing Address - State:MI
Mailing Address - Zip Code:49508-5295
Mailing Address - Country:US
Mailing Address - Phone:616-455-3020
Mailing Address - Fax:616-455-1397
Practice Address - Street 1:2351 COUNTRYWOOD DR SE
Practice Address - Street 2:SUITE B
Practice Address - City:KENTWOOD
Practice Address - State:MI
Practice Address - Zip Code:49508-5295
Practice Address - Country:US
Practice Address - Phone:616-455-3020
Practice Address - Fax:616-455-1397
Is Sole Proprietor?:Yes
Enumeration Date:2011-05-27
Last Update Date:2011-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI53150502581223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice