Provider Demographics
NPI:1922558964
Name:JOHN D MANCINI DDS PC
Entity Type:Organization
Organization Name:JOHN D MANCINI DDS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:D
Authorized Official - Last Name:MANCINI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:269-651-6345
Mailing Address - Street 1:1415 S LAKEVIEW AVE
Mailing Address - Street 2:
Mailing Address - City:STURGIS
Mailing Address - State:MI
Mailing Address - Zip Code:49091-2350
Mailing Address - Country:US
Mailing Address - Phone:269-651-6345
Mailing Address - Fax:
Practice Address - Street 1:1415 S LAKEVIEW AVE
Practice Address - Street 2:
Practice Address - City:STURGIS
Practice Address - State:MI
Practice Address - Zip Code:49091-2350
Practice Address - Country:US
Practice Address - Phone:269-651-6345
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-10-13
Last Update Date:2016-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIP05230001OtherMEDICARE IDENTIFICATION NUMBER (PTAN)