Healthcare Provider Details

I. General information

NPI: 1285181016
Provider Name (Legal Business Name): LOUISON LEONARD MANNINGHAM JR. D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/09/2016
Last Update Date: 09/09/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4911 W ST JOE HWY
LANSING MI
48917-4088
US

IV. Provider business mailing address

4911 W ST JOE HWY
LANSING MI
48917-4088
US

V. Phone/Fax

Practice location:
  • Phone: 517-321-1848
  • Fax:
Mailing address:
  • Phone: 517-321-1848
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number2901022063
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: