Provider Demographics
NPI:1821190794
Name:MANOUS, JOHANNA KAY (DDS)
Entity Type:Individual
Prefix:DR
First Name:JOHANNA
Middle Name:KAY
Last Name:MANOUS
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9305 CALUMET AVE
Mailing Address - Street 2:SUITE D1
Mailing Address - City:MUNSTER
Mailing Address - State:IN
Mailing Address - Zip Code:46321-2887
Mailing Address - Country:US
Mailing Address - Phone:219-836-2041
Mailing Address - Fax:219-836-2410
Practice Address - Street 1:9305 CALUMET AVE
Practice Address - Street 2:SUITE D1
Practice Address - City:MUNSTER
Practice Address - State:IN
Practice Address - Zip Code:46321-2887
Practice Address - Country:US
Practice Address - Phone:219-836-2041
Practice Address - Fax:219-836-2410
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN120090791223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice