Provider Demographics
NPI:1639328677
Name:MANTINAOS, JOHN (DMD)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:
Last Name:MANTINAOS
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5203 BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:QUINCY
Mailing Address - State:IL
Mailing Address - Zip Code:62305-9110
Mailing Address - Country:US
Mailing Address - Phone:217-577-2400
Mailing Address - Fax:217-228-1032
Practice Address - Street 1:5203 BROADWAY ST
Practice Address - Street 2:
Practice Address - City:QUINCY
Practice Address - State:IL
Practice Address - Zip Code:62305-9110
Practice Address - Country:US
Practice Address - Phone:217-577-2400
Practice Address - Fax:217-228-1032
Is Sole Proprietor?:No
Enumeration Date:2008-09-15
Last Update Date:2014-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY048817-1122300000X
IN12011569A122300000X
IL019028483122300000X
NJ22DI02373800122300000X
PADS036424122300000X
MADN20160122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist