Provider Demographics
NPI:1699885319
Name:MANAUTOU, MARIA A (DDS)
Entity type:Individual
Prefix:DR
First Name:MARIA
Middle Name:A
Last Name:MANAUTOU
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20901 MOROSS RD
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48236-2058
Mailing Address - Country:US
Mailing Address - Phone:313-626-2620
Mailing Address - Fax:313-626-2605
Practice Address - Street 1:20901 MOROSS RD
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48236-2058
Practice Address - Country:US
Practice Address - Phone:313-626-2620
Practice Address - Fax:313-626-2605
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2015-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2901017368122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4593382Medicaid
MI4197209Medicaid