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General NPI Number Information
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NPI Number | 1346508124
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Entity Type | Organization
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Legal Business Name | DR. GARY W. MANCEWICZ DDS
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Dates
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Enumeration Date | 04/30/2012
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Last Update Date | 04/30/2012
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Provider Practice Location Address
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Address Line | 2351 COUNTRYWOOD DR SE
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City | KENTWOOD
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State | MI
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Zip | 49508-5295
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Country | US
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Telephone | 616-455-3020
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Fax | 616-455-1397
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Provider Business Mailing Address
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Address Line | 2351 COUNTRYWOOD DR SE
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City | KENTWOOD
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State | MI
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Zip | 49508-5295
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Country | US
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Telephone | 616-455-3020
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Fax | 616-455-1397
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Authorized Official
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Title or Position | OWNER/DENTIST
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Name | MR. GARY W MANCEWICZ
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Credential | DDS
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Telephone | 616-455-3020
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | 2901011327
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License Number State | MI
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