Provider Demographics
NPI:1710193917
Name:MANTIS, KONSTANTINO J (DDS)
Entity Type:Individual
Prefix:DR
First Name:KONSTANTINO
Middle Name:J
Last Name:MANTIS
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:DR
Other - First Name:DINO
Other - Middle Name:J
Other - Last Name:MANTIS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DDS
Mailing Address - Street 1:796 STATE LINE RD
Mailing Address - Street 2:
Mailing Address - City:CALUMET CITY
Mailing Address - State:IL
Mailing Address - Zip Code:60409-4643
Mailing Address - Country:US
Mailing Address - Phone:708-862-6970
Mailing Address - Fax:708-862-6975
Practice Address - Street 1:796 STATE LINE RD
Practice Address - Street 2:
Practice Address - City:CALUMET CITY
Practice Address - State:IL
Practice Address - Zip Code:60409-4643
Practice Address - Country:US
Practice Address - Phone:708-862-6970
Practice Address - Fax:708-862-6975
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice