Provider Demographics
NPI:1740283605
Name:MANTOAN, RICHARD J (DDS)
Entity type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:J
Last Name:MANTOAN
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19815 GOVERNORS HWY
Mailing Address - Street 2:STE 7
Mailing Address - City:FLOSSMOOR
Mailing Address - State:IL
Mailing Address - Zip Code:60422-4388
Mailing Address - Country:US
Mailing Address - Phone:708-799-7800
Mailing Address - Fax:708-799-4864
Practice Address - Street 1:19815 GOVERNORS HWY
Practice Address - Street 2:STE 7
Practice Address - City:FLOSSMOOR
Practice Address - State:IL
Practice Address - Zip Code:60422-4388
Practice Address - Country:US
Practice Address - Phone:708-799-7800
Practice Address - Fax:708-799-4864
Is Sole Proprietor?:No
Enumeration Date:2005-05-24
Last Update Date:2007-07-08
Deactivation Date:2006-03-16
Deactivation Code:
Reactivation Date:2006-03-20
Provider Licenses
StateLicense IDTaxonomies
IL19A153081223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice