Provider Demographics
NPI:1962459636
Name:MANTEGARI, STEVEN A (DDS, MD)
Entity Type:Individual
Prefix:DR
First Name:STEVEN
Middle Name:A
Last Name:MANTEGARI
Suffix:
Gender:M
Credentials:DDS, MD
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Mailing Address - Street 1:1866 EPPING FOREST WAY S
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32217-2670
Mailing Address - Country:US
Mailing Address - Phone:904-527-8979
Mailing Address - Fax:904-652-1666
Practice Address - Street 1:4765 HODGES BLVD STE 6
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32224-5279
Practice Address - Country:US
Practice Address - Phone:904-821-8881
Practice Address - Fax:904-652-1666
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-28
Last Update Date:2021-12-29
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MO0154301223S0112X
FLDN148891223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOU73848Medicare UPIN