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General NPI Number Information
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NPI Number | 1619640752
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Entity Type | Individual
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Provider Name | YOUSTINA MANTIAS DDS
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Gender | Female
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Dates
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Enumeration Date | 07/26/2021
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Last Update Date | 07/26/2021
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Provider Practice Location Address
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Address Line | 63 W PROSPECT ST
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City | EAST BRUNSWICK
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State | NJ
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Zip | 08816-5705
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Country | US
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Telephone | 347-830-5946
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Fax |
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Provider Business Mailing Address
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Address Line | 15 SANIBEL CT
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City | MONROE
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State | NJ
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Zip | 08831-5816
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Country | US
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Telephone | 347-830-5946
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Fax |
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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 | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | 22DI02854600
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License Number State | NJ
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