Healthcare Provider Details

I. General information

NPI: 1134391675
Provider Name (Legal Business Name): AGISILAOS PETER MANICKAS D.M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/25/2008
Last Update Date: 12/14/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

803 MASS AVE
LEXINGTON MA
02420-3918
US

IV. Provider business mailing address

803 MASS AVE
LEXINGTON MA
02420-3918
US

V. Phone/Fax

Practice location:
  • Phone: 781-862-8220
  • Fax: 781-862-3050
Mailing address:
  • Phone: 781-862-8220
  • Fax: 781-862-3050

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0700X
TaxonomyProsthodontics
License Number8886
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: