Provider Demographics
NPI:1366512113
Name:MANTOOTH, HERBERT C (DDS)
Entity type:Individual
Prefix:
First Name:HERBERT
Middle Name:C
Last Name:MANTOOTH
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:602 RAILROAD AVE SE
Mailing Address - Street 2:
Mailing Address - City:LIVE OAK
Mailing Address - State:FL
Mailing Address - Zip Code:32064-3418
Mailing Address - Country:US
Mailing Address - Phone:386-362-6556
Mailing Address - Fax:362-362-5769
Practice Address - Street 1:602 RAILROAD AVE SE
Practice Address - Street 2:
Practice Address - City:LIVE OAK
Practice Address - State:FL
Practice Address - Zip Code:32064-3418
Practice Address - Country:US
Practice Address - Phone:386-362-6556
Practice Address - Fax:362-362-5769
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL74541223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice