Provider Demographics
NPI:1669688875
Name:MANTIS DENTISTRY
Entity type:Organization
Organization Name:MANTIS DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CHRISTINA
Authorized Official - Middle Name:
Authorized Official - Last Name:MANTIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:708-903-6110
Mailing Address - Street 1:796 STATE LINE RD
Mailing Address - Street 2:
Mailing Address - City:CALUMET CITY
Mailing Address - State:IL
Mailing Address - Zip Code:60409-4643
Mailing Address - Country:US
Mailing Address - Phone:708-862-6970
Mailing Address - Fax:708-862-6975
Practice Address - Street 1:796 STATE LINE RD
Practice Address - Street 2:
Practice Address - City:CALUMET CITY
Practice Address - State:IL
Practice Address - Zip Code:60409-4643
Practice Address - Country:US
Practice Address - Phone:708-862-6970
Practice Address - Fax:708-862-6975
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-15
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty