Provider Demographics
NPI:1295941607
Name:MANTHOS, LAURIE (DMD)
Entity type:Individual
Prefix:DR
First Name:LAURIE
Middle Name:
Last Name:MANTHOS
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 LINCOLN ST
Mailing Address - Street 2:SUITE 1
Mailing Address - City:WORCESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01605-2528
Mailing Address - Country:US
Mailing Address - Phone:508-752-2100
Mailing Address - Fax:508-752-0304
Practice Address - Street 1:200 LINCOLN ST
Practice Address - Street 2:SUITE 1
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01605-2528
Practice Address - Country:US
Practice Address - Phone:508-752-2100
Practice Address - Fax:508-752-0304
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA168231223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAX06437Medicare ID - Type Unspecified
MAU18525Medicare UPIN