Provider Demographics
NPI:1255422853
Name:MANTANONA, CLARISA KIM (DDS)
Entity type:Individual
Prefix:DR
First Name:CLARISA
Middle Name:KIM
Last Name:MANTANONA
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 1:1920 VINDICATOR DR
Mailing Address - Street 2:SUITE 211
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80919-3624
Mailing Address - Country:US
Mailing Address - Phone:719-314-2088
Mailing Address - Fax:719-314-2089
Practice Address - Street 1:1920 VINDICATOR DR
Practice Address - Street 2:SUITE 211
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80919-3624
Practice Address - Country:US
Practice Address - Phone:719-314-2088
Practice Address - Fax:719-314-2089
Is Sole Proprietor?:No
Enumeration Date:2006-09-27
Last Update Date:2010-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO90251223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice