Provider Demographics
NPI:1346424348
Name:MANN, RONALD G (DDS)
Entity Type:Individual
Prefix:DR
First Name:RONALD
Middle Name:G
Last Name:MANN
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:P. O. BOX 1003
Mailing Address - Street 2:104 PHILIP AVE.
Mailing Address - City:PHILIP
Mailing Address - State:SD
Mailing Address - Zip Code:57567-1003
Mailing Address - Country:US
Mailing Address - Phone:605-859-2491
Mailing Address - Fax:
Practice Address - Street 1:104 PHILIP AVE.
Practice Address - Street 2:
Practice Address - City:PHILIP
Practice Address - State:SD
Practice Address - Zip Code:57567-1003
Practice Address - Country:US
Practice Address - Phone:605-859-2491
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-27
Last Update Date:2007-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SDM-6481223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD780-4610Medicaid