Healthcare Provider Details

I. General information

NPI: 1962459636
Provider Name (Legal Business Name): STEVEN A MANTEGARI DDS, MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/28/2006
Last Update Date: 06/04/2025
Certification Date: 06/04/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4765 HODGES BLVD STE 6
JACKSONVILLE FL
32224-5279
US

IV. Provider business mailing address

1866 EPPING FOREST WAY S
JACKSONVILLE FL
32217-2670
US

V. Phone/Fax

Practice location:
  • Phone: 904-821-8881
  • Fax: 904-652-1666
Mailing address:
  • Phone: 904-527-8979
  • Fax: 904-652-1666

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code204E00000X
TaxonomyOral & Maxillofacial Surgery (D.M.D.)
License NumberDR.0075408
License Number StateCO
# 2
Primary TaxonomyN
Taxonomy Code204E00000X
TaxonomyOral & Maxillofacial Surgery (D.M.D.)
License Number015430
License Number StateMO
# 3
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberDN14889
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: