Provider Demographics
NPI:1508961533
Name:MANDATO, THADDEUS JUDE JOHN (DDS)
Entity Type:Individual
Prefix:DR
First Name:THADDEUS JUDE
Middle Name:JOHN
Last Name:MANDATO
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 1:21245 LORAIN RD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:FAIRVIEW PARK
Mailing Address - State:OH
Mailing Address - Zip Code:44126-2146
Mailing Address - Country:US
Mailing Address - Phone:440-331-0164
Mailing Address - Fax:440-331-0165
Practice Address - Street 1:21245 LORAIN RD
Practice Address - Street 2:SUITE 100
Practice Address - City:FAIRVIEW PARK
Practice Address - State:OH
Practice Address - Zip Code:44126-2146
Practice Address - Country:US
Practice Address - Phone:440-331-0164
Practice Address - Fax:440-331-0165
Is Sole Proprietor?:No
Enumeration Date:2006-09-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH30-01-51811223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice