Provider Demographics
NPI:1730670639
Name:MCMANNES, KATHLEEN (LDH)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:
Last Name:MCMANNES
Suffix:
Gender:F
Credentials:LDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1267 W 95TH PL
Mailing Address - Street 2:
Mailing Address - City:CROWN POINT
Mailing Address - State:IN
Mailing Address - Zip Code:46307-2276
Mailing Address - Country:US
Mailing Address - Phone:219-628-5295
Mailing Address - Fax:
Practice Address - Street 1:4629 MELTON RD
Practice Address - Street 2:
Practice Address - City:GARY
Practice Address - State:IN
Practice Address - Zip Code:46403-2866
Practice Address - Country:US
Practice Address - Phone:219-938-2637
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-25
Last Update Date:2018-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN13007475A124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist