Provider Demographics
NPI:1023234150
Name:RAYMOND D.MANNIELLO,D.D.S.,P.C.
Entity type:Organization
Organization Name:RAYMOND D.MANNIELLO,D.D.S.,P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:RAYMOND
Authorized Official - Middle Name:
Authorized Official - Last Name:MANNIELLO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:413-525-0861
Mailing Address - Street 1:264 N MAIN ST
Mailing Address - Street 2:SUITE 4
Mailing Address - City:EAST LONGMEADOW
Mailing Address - State:MA
Mailing Address - Zip Code:01028-1815
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:264 N MAIN ST
Practice Address - Street 2:SUITE 4
Practice Address - City:EAST LONGMEADOW
Practice Address - State:MA
Practice Address - Zip Code:01028-1815
Practice Address - Country:US
Practice Address - Phone:413-525-0861
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-17
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAMA180811223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAMA18081OtherSTATE LICENSE NUMBER