Provider Demographics
NPI:1346508124
Name:DR. GARY W. MANCEWICZ DDS
Entity Type:Organization
Organization Name:DR. GARY W. MANCEWICZ DDS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DENTIST
Authorized Official - Prefix:MR
Authorized Official - First Name:GARY
Authorized Official - Middle Name:W
Authorized Official - Last Name:MANCEWICZ
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:616-455-3020
Mailing Address - Street 1:2351 COUNTRYWOOD DR SE
Mailing Address - Street 2:
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:
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
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-04-30
Last Update Date:2012-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29010113271223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4828774Medicaid