Provider Demographics
NPI:1801966767
Name:MANCEWICZ, GARY W (DDS)
Entity type:Individual
Prefix:DR
First Name:GARY
Middle Name:W
Last Name:MANCEWICZ
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:2351 COUNTRYWOOD DR. SE
Mailing Address - Street 2:SUITE B
Mailing Address - City:KENTWOOD
Mailing Address - State:FM
Mailing Address - Zip Code:49508
Mailing Address - Country:US
Mailing Address - Phone:616-455-3020
Mailing Address - Fax:616-455-1397
Practice Address - Street 1:2351 COUNTRYWOOD DR SE
Practice Address - Street 2:SUITE B
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49508-5065
Practice Address - Country:US
Practice Address - Phone:616-455-3020
Practice Address - Fax:616-455-1397
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29-01-011327122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4828774Medicaid