Provider Demographics
NPI:1932401783
Name:MATIN, MANI
Entity Type:Individual
Prefix:
First Name:MANI
Middle Name:
Last Name:MATIN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:46 HARLEY DR
Mailing Address - Street 2:
Mailing Address - City:WORCESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01606-1771
Mailing Address - Country:US
Mailing Address - Phone:703-946-6412
Mailing Address - Fax:
Practice Address - Street 1:68 STAFFORD ST
Practice Address - Street 2:
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01603-1450
Practice Address - Country:US
Practice Address - Phone:703-946-6412
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-11-30
Last Update Date:2014-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA59929122300000X
MADN1856285122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist