Healthcare Provider Details

I. General information

NPI: 1326465824
Provider Name (Legal Business Name): JESSE W. MANTON DDS, MS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/21/2014
Last Update Date: 10/01/2020
Certification Date: 10/01/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

155 5TH ST
SAN FRANCISCO CA
94103-2919
US

IV. Provider business mailing address

155 5TH ST
SAN FRANCISCO CA
94103-2919
US

V. Phone/Fax

Practice location:
  • Phone: 415-929-6690
  • Fax: 415-749-3305
Mailing address:
  • Phone: 415-929-6690
  • Fax: 415-749-3305

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number30.025706
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code1223D0004X
TaxonomyDental Anesthesiology
License Number30.025706
License Number StateOH
# 3
Primary TaxonomyN
Taxonomy Code1223D0004X
TaxonomyDental Anesthesiology
License Number30.25706
License Number StateOH
# 4
Primary TaxonomyY
Taxonomy Code1223D0004X
TaxonomyDental Anesthesiology
License NumberCA64852
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: