MEDICARE: DR. AGISILAOS PETER MANICKAS D.M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223P0700X	Prosthodontics	8886	MA

General Provider Information

NPI Number	:	1134391675
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. AGISILAOS PETER MANICKAS D.M.D.

Provider Business Mailing Address
First Line	:	803 MASS AVE
Second Line	:
City	:	LEXINGTON
State	:	MA
Zip	:	02420-3918
Country	:	US
Telephone Number	:	781-862-8220
Fax Number	:	781-862-3050

Provider Business Practice Location Address
First Line	:	803 MASS AVE
Second Line	:
City	:	LEXINGTON
State	:	MA
Zip	:	02420-3918
Country	:	US
Telephone Number	:	781-862-8220
Fax Number	:	781-862-3050

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/25/2008
Last Update Date	:	12/14/2025

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