Provider Demographics
NPI:1316555253
Name:MANTENA DENTAL CORPORTATION
Entity Type:Organization
Organization Name:MANTENA DENTAL CORPORTATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MORGAN
Authorized Official - Middle Name:
Authorized Official - Last Name:MACDOUGALL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:916-599-6767
Mailing Address - Street 1:25005 BLUE RAVINE RD STE 100
Mailing Address - Street 2:
Mailing Address - City:FOLSOM
Mailing Address - State:CA
Mailing Address - Zip Code:95630-5706
Mailing Address - Country:US
Mailing Address - Phone:916-984-8050
Mailing Address - Fax:
Practice Address - Street 1:25005 BLUE RAVINE RD STE 100
Practice Address - Street 2:
Practice Address - City:FOLSOM
Practice Address - State:CA
Practice Address - Zip Code:95630-5706
Practice Address - Country:US
Practice Address - Phone:916-984-8050
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-07-16
Last Update Date:2020-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty