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General NPI Number Information
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NPI Number | 1295941607
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Entity Type | Individual
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Provider Name | LAURIE MANTHOS D.M.D.
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Gender | Female
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Dates
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Enumeration Date | 05/15/2007
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Last Update Date | 07/08/2007
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Provider Practice Location Address
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Address Line | 200 LINCOLN ST SUITE 1
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City | WORCESTER
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State | MA
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Zip | 01605-2528
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Country | US
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Telephone | 508-752-2100
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Fax | 508-752-0304
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Provider Business Mailing Address
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Address Line | 200 LINCOLN ST SUITE 1
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City | WORCESTER
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State | MA
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Zip | 01605-2528
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Country | US
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Telephone | 508-752-2100
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Fax | 508-752-0304
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223S0112X
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Taxonomy Name | Oral and Maxillofacial Surgery (Dentist)
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License Number | 16823
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License Number State | MA
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