Provider Demographics
NPI:1508876566
Name:MANTEI, KELLY CARROTHERS (DDS)
Entity Type:Individual
Prefix:DR
First Name:KELLY
Middle Name:CARROTHERS
Last Name:MANTEI
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:MRS
Other - First Name:KELLY
Other - Middle Name:CARROTHERS
Other - Last Name:MANTEI
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:2225 A1A S STE A3
Mailing Address - Street 2:
Mailing Address - City:ST AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32080-6374
Mailing Address - Country:US
Mailing Address - Phone:904-471-7300
Mailing Address - Fax:
Practice Address - Street 1:2225 A1A S STE A3
Practice Address - Street 2:
Practice Address - City:ST AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32080-6374
Practice Address - Country:US
Practice Address - Phone:904-471-7300
Practice Address - Fax:904-471-2708
Is Sole Proprietor?:No
Enumeration Date:2006-08-09
Last Update Date:2016-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN150671223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice