Provider Demographics
NPI:1831178730
Name:MANSOLILLO, JEFFREY BRIAN (DMD)
Entity type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:BRIAN
Last Name:MANSOLILLO
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 1:1347 HARTFORD AVE
Mailing Address - Street 2:
Mailing Address - City:JOHNSTON
Mailing Address - State:RI
Mailing Address - Zip Code:02919
Mailing Address - Country:US
Mailing Address - Phone:401-861-1080
Mailing Address - Fax:401-861-5106
Practice Address - Street 1:1347 HARTFORD AVE
Practice Address - Street 2:
Practice Address - City:JOHNSTON
Practice Address - State:RI
Practice Address - Zip Code:02919
Practice Address - Country:US
Practice Address - Phone:401-861-1080
Practice Address - Fax:401-861-5106
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RI2648122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist