Provider Demographics
NPI:1558647586
Name:MANNINO, TROY M (DDS)
Entity Type:Individual
Prefix:DR
First Name:TROY
Middle Name:M
Last Name:MANNINO
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 1:3099 CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:LAKE STATION
Mailing Address - State:IN
Mailing Address - Zip Code:46405-2207
Mailing Address - Country:US
Mailing Address - Phone:219-763-8112
Mailing Address - Fax:
Practice Address - Street 1:3099 CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:LAKE STATION
Practice Address - State:IN
Practice Address - Zip Code:46405-2207
Practice Address - Country:US
Practice Address - Phone:219-763-8112
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-10-21
Last Update Date:2011-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12011729A122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist