Provider Demographics
NPI:1508327784
Name:ROY, MANAR
Entity Type:Individual
Prefix:DR
First Name:MANAR
Middle Name:
Last Name:ROY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 TANNERY BROOK ROW UNIT 3B
Mailing Address - Street 2:
Mailing Address - City:SOMERVILLE
Mailing Address - State:MA
Mailing Address - Zip Code:02144-2765
Mailing Address - Country:US
Mailing Address - Phone:504-617-0081
Mailing Address - Fax:
Practice Address - Street 1:822 BOYLSTON ST STE 200
Practice Address - Street 2:
Practice Address - City:CHESTNUT HILL
Practice Address - State:MA
Practice Address - Zip Code:02467-2504
Practice Address - Country:US
Practice Address - Phone:617-315-2573
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-29
Last Update Date:2024-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH30026097122300000X
NC126321223G0001X
MADN18597411223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0355917Medicaid