Healthcare Provider Details

I. General information

NPI: 1801966767
Provider Name (Legal Business Name): GARY W. MANCEWICZ D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/08/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2351 COUNTRYWOOD DR SE SUITE B
GRAND RAPIDS MI
49508-5065
US

IV. Provider business mailing address

2351 COUNTRYWOOD DR. SE SUITE B
KENTWOOD FM
49508
US

V. Phone/Fax

Practice location:
  • Phone: 616-455-3020
  • Fax: 616-455-1397
Mailing address:
  • Phone: 616-455-3020
  • Fax: 616-455-1397

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number29-01-011327
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: