Healthcare Provider Details

I. General information

NPI: 1285750596
Provider Name (Legal Business Name): LAURIE MANTHOS, D.M.D., P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/21/2007
Last Update Date: 01/11/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 LINCOLN ST SUITE 1
WORCESTER MA
01605-2528
US

IV. Provider business mailing address

200 LINCOLN ST SUITE 1
WORCESTER MA
01605-2528
US

V. Phone/Fax

Practice location:
  • Phone: 508-752-2100
  • Fax:
Mailing address:
  • Phone: 508-752-2100
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number16823
License Number StateMA

VIII. Authorized Official

Name: DR. LAURIE MANTHOS
Title or Position: OWNER
Credential: D.M.D.
Phone: 508-752-2100