Provider Demographics
NPI:1013174788
Name:MANDISH, NANCY MARIE (DDS)
Entity Type:Individual
Prefix:
First Name:NANCY
Middle Name:MARIE
Last Name:MANDISH
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:PO BOX 2147
Mailing Address - Street 2:
Mailing Address - City:IRMO
Mailing Address - State:SC
Mailing Address - Zip Code:29063-7147
Mailing Address - Country:US
Mailing Address - Phone:803-781-8114
Mailing Address - Fax:
Practice Address - Street 1:1380 LAKE MURRAY BLVD
Practice Address - Street 2:
Practice Address - City:IRMO
Practice Address - State:SC
Practice Address - Zip Code:29063-2836
Practice Address - Country:US
Practice Address - Phone:803-781-8114
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-20
Last Update Date:2008-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC2194122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist