Provider Demographics
NPI:1831215912
Name:MANNARINO, NICHOLAS A (D D S)
Entity type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:A
Last Name:MANNARINO
Suffix:
Gender:M
Credentials:D D S
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5902 RAYMOND RD
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53711-4100
Mailing Address - Country:US
Mailing Address - Phone:608-271-5212
Mailing Address - Fax:
Practice Address - Street 1:5902 RAYMOND RD
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53711-4100
Practice Address - Country:US
Practice Address - Phone:608-271-5212
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5000438122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI5000438OtherWISCONSIN DENTAL LICENSE