Healthcare Provider Details

I. General information

NPI: 1992390751
Provider Name (Legal Business Name): PANAGIOTIS MANETAS DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/03/2021
Last Update Date: 06/04/2022
Certification Date: 06/04/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 KNEELAND ST
BOSTON MA
02111-1527
US

IV. Provider business mailing address

45 STUART ST APT 2110
BOSTON MA
02116-4768
US

V. Phone/Fax

Practice location:
  • Phone: 617-636-6515
  • Fax:
Mailing address:
  • Phone: 857-919-3983
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDL15125
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: