Healthcare Provider Details

I. General information

NPI: 1508196890
Provider Name (Legal Business Name): ANDREW J. MANTEL, PC,
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/08/2010
Last Update Date: 01/08/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

150 09 89TH STREET
HOWARD BEACH NY
11414
US

IV. Provider business mailing address

150 09 89TH STREET
HOWARD BEACH NY
11414
US

V. Phone/Fax

Practice location:
  • Phone: 718-641-1333
  • Fax: 718-641-9156
Mailing address:
  • Phone: 718-641-1333
  • Fax: 718-641-9156

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier01612582
Identifier TypeMEDICAID
Identifier StateNY
Identifier Issuer

VIII. Authorized Official

Name: DR. ANDRE J. MANTEL
Title or Position: DENTIST
Credential: DMD
Phone: 718-641-1333